MEDICARE: MARINA SHORES OB/GYN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	0101256943	VA
2	363LX0001X	Obstetrics & Gynecology Nurse Practitioner	0101256943	VA
3	207V00000X	Obstetrics & Gynecology Physician	0101256943	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1417492034	OTHER	VA	GROUP- NPI

General Provider Information

NPI Number	:	1417492034
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARINA SHORES OB/GYN

Provider Business Mailing Address
First Line	:	2865 LYNNHAVEN DR
Second Line	:	SUITE 4A
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23451-1542
Country	:	US
Telephone Number	:	757-496-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	2865 LYNNHAVEN DR
Second Line	:	SUITE 4A
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23451-1542
Country	:	US
Telephone Number	:	757-496-5000
Fax Number	:

Authorized Official
Title or Position	:	OB/GYN PHYSICIAN
Name	:	DR. LANI MARIE WARREN
Credential	:	MD
Telephone Number	:	757-496-5000

Provider Enumeration Date	:	01/05/2017
Last Update Date	:	03/24/2017

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Directions to “MARINA SHORES OB/GYN ” Practice Location

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