Basic Information
| Provider Information | |||||||||
| NPI: | 1336545771 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARINE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | |||||||||
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| Credential: | IBCLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 595 CENTER AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | MARTINEZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945534634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9253136098 | ||||||||
| FaxNumber: | 9253136599 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 ALLEN ST | ||||||||
| Address2: | |||||||||
| City: | MARTINEZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945532681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9253136098 | ||||||||
| FaxNumber: | 9253136599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2014 | ||||||||
| LastUpdateDate: | 11/12/2014 | ||||||||
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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 | 174N00000X | 10218424 | CA | Y | Other Service Providers | Lactation Consultant, Non-RN |
No ID Information.