Healthcare Provider Details

I. General information

NPI: 1730873753
Provider Name (Legal Business Name): TARENA MARSHALL LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 06/05/2023
Certification Date: 06/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 MAIN ST
GRAMBLING LA
71245-2715
US

IV. Provider business mailing address

110 FAITH LN
MENDENHALL MS
39114-5831
US

V. Phone/Fax

Practice location:
  • Phone: 601-382-5170
  • Fax:
Mailing address:
  • Phone: 601-382-5170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number320938
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: