Provider Demographics
NPI:1447838917
Name:ITZOE, MARIALISA SHERIDAN MILLS (DO/MPH)
Entity type:Individual
Prefix:
First Name:MARIALISA
Middle Name:SHERIDAN MILLS
Last Name:ITZOE
Suffix:
Gender:F
Credentials:DO/MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 N 47TH ST APT 704
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-1543
Mailing Address - Country:US
Mailing Address - Phone:443-824-3213
Mailing Address - Fax:
Practice Address - Street 1:800 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-6192
Practice Address - Country:US
Practice Address - Phone:215-829-3309
Practice Address - Fax:215-829-7129
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program