Healthcare Provider Details

I. General information

NPI: 1487199295
Provider Name (Legal Business Name): EMILY MORGAN MARRIOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: EMILY MORGAN MARRIOTT PTA

II. Dates (important events)

Enumeration Date: 01/03/2017
Last Update Date: 01/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 WINN DR STE 100
REXBURG ID
83440-5277
US

IV. Provider business mailing address

66 S 1ST W
REXBURG ID
83440-1815
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-0174
  • Fax: 208-356-0176
Mailing address:
  • Phone: 253-508-9472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA-4834
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: