Healthcare Provider Details

I. General information

NPI: 1710028089
Provider Name (Legal Business Name): MARILYN H DRAPER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARILYN REYES

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 03/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 OAKLAND AVE
ELKHART IN
46517-1533
US

IV. Provider business mailing address

109 N 3RD ST
NILES MI
49120-2655
US

V. Phone/Fax

Practice location:
  • Phone: 574-533-1234
  • Fax: 574-537-2652
Mailing address:
  • Phone: 574-533-1234
  • Fax: 574-537-2652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: