1104754019 NPI number — MS. MARION VILLAHERMOSA HERMITANIO

Table of content: MS. MARION VILLAHERMOSA HERMITANIO (NPI 1104754019)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104754019 NPI number — MS. MARION VILLAHERMOSA HERMITANIO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERMITANIO
Provider First Name:
MARION
Provider Middle Name:
VILLAHERMOSA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104754019
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/11/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2259 RED TAIL GLN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DE PERE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54115-1631
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-664-1575
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
539 LAVERNE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREEN BAY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54311-5720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-391-2410
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/11/2026

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  922209 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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