Provider Demographics
NPI:1770286668
Name:VANILLO, MARC
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:VANILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 SW 20TH AVE APT 108
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-3525
Mailing Address - Country:US
Mailing Address - Phone:917-544-4844
Mailing Address - Fax:
Practice Address - Street 1:110 REHILL AVE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08876-2519
Practice Address - Country:US
Practice Address - Phone:908-685-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-22
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11024787363LG0600X
NJ26NJ01461700363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology