Healthcare Provider Details

I. General information

NPI: 1760324719
Provider Name (Legal Business Name): TAMARA DENISE MARSHALL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2026
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 FERRY ST STE B
LAFAYETTE IN
47901-1172
US

IV. Provider business mailing address

1116 S 23RD ST
LAFAYETTE IN
47905-1627
US

V. Phone/Fax

Practice location:
  • Phone: 765-581-3121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28151570A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: