Provider Demographics
NPI:1801618483
Name:MARQUEZ, LETICIA GONZALEZ
Entity type:Individual
Prefix:
First Name:LETICIA
Middle Name:GONZALEZ
Last Name:MARQUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 COUNTRY DR
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-3327
Mailing Address - Country:US
Mailing Address - Phone:209-737-6021
Mailing Address - Fax:
Practice Address - Street 1:2520 COUNTRY DR
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-3327
Practice Address - Country:US
Practice Address - Phone:209-737-6021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-25
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC3283053172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver