MEDICARE: MARIE ANNETTE OHAVER FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	243646	AZ
2	363LP2300X	Primary Care Nurse Practitioner	243646	AZ
3	363LF0000X	Family Nurse Practitioner	243646	AZ

General Provider Information

NPI Number	:	1396370607
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIE ANNETTE OHAVER FNP

Provider Business Mailing Address
First Line	:	1720 MESQUITE AVE STE 100
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5602
Country	:	US
Telephone Number	:	928-412-8088
Fax Number	:	928-412-8807

Provider Business Practice Location Address
First Line	:	1720 MESQUITE AVE STE 100
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5602
Country	:	US
Telephone Number	:	928-412-8088
Fax Number	:	928-412-8807

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2020
Last Update Date	:	06/29/2023

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