Basic Information
| Provider Information | |||||||||
| NPI: | 1083260780 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATRICK | ||||||||
| FirstName: | MARCI | ||||||||
| MiddleName: | DEANNA | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FLYNT | ||||||||
| OtherFirstName: | MARCI | ||||||||
| OtherMiddleName: | DEANNA | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 301 W LOCUST ST | ||||||||
| Address2: | |||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952402015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2096632302 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 441 S HAM LN STE A | ||||||||
| Address2: | |||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952423525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092248940 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2019 | ||||||||
| LastUpdateDate: | 08/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | 180380 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.