Healthcare Provider Details

I. General information

NPI: 1841239258
Provider Name (Legal Business Name): ROSEANNE M MARRA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3175 LENOX PARK BLVD SUITE 412
MEMPHIS TN
38115-4260
US

IV. Provider business mailing address

3175 LENOX PARK BLVD SUITE 412
MEMPHIS TN
38115-4260
US

V. Phone/Fax

Practice location:
  • Phone: 901-273-2368
  • Fax: 901-273-2351
Mailing address:
  • Phone: 901-273-2368
  • Fax: 901-273-2351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP 15363
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: