Provider Demographics
NPI:1902054166
Name:MOREIRA, MARILYN S C (LPN)
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:S C
Last Name:MOREIRA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 DEANNA RD
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-4427
Mailing Address - Country:US
Mailing Address - Phone:508-587-1430
Mailing Address - Fax:
Practice Address - Street 1:167 DEANNA RD
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-4427
Practice Address - Country:US
Practice Address - Phone:508-587-1430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-29
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA54176164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0717835OtherMASSHEALTH PROVIDER NUMBER