Healthcare Provider Details

I. General information

NPI: 1275517674
Provider Name (Legal Business Name): MARINA LANS EARLY NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 09/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 TYDD STREET
EUREKA CA
95501-1284
US

IV. Provider business mailing address

670 9TH STREET SUITE 203
ARCATA CA
95521-6249
US

V. Phone/Fax

Practice location:
  • Phone: 707-441-1624
  • Fax: 707-441-1253
Mailing address:
  • Phone: 707-826-8633
  • Fax: 707-826-8638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN351484
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8371
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: