1336719400 NPI number — LIBBE BLYTHE MARQUEZ APRN AGCNS-BC

Table of content: ISABELLA FERNANDA LONDONDO RAIOLA (NPI 1235950478)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336719400 NPI number — LIBBE BLYTHE MARQUEZ APRN AGCNS-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARQUEZ
Provider First Name:
LIBBE
Provider Middle Name:
BLYTHE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN AGCNS-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TOLLEFSON
Provider Other First Name:
LIBBE
Provider Other Middle Name:
BLYTHE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN AGCNS-BC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1336719400
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12697 E 51ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74146-6236
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-505-3200
Provider Business Mailing Address Fax Number:
918-505-3225

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12697 E 51ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74146-6236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-505-3200
Provider Business Practice Location Address Fax Number:
918-505-3225
Provider Enumeration Date:
06/30/2021

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: 364S00000X , with the licence number:  R0124884 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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