MEDICARE: NICOLE RENE MARIETTA DO

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	207V00000X	Obstetrics & Gynecology Physician	M2390	TX
2	207Q00000X	Family Medicine Physician	M2390	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639189632
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE RENE MARIETTA DO

Provider Business Mailing Address
First Line	:	PO BOX 844658
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-4658
Country	:	US
Telephone Number	:	800-994-0371
Fax Number	:

Provider Business Practice Location Address
First Line	:	4035 STATE HIGHWAY 6 S
Second Line	:
City	:	COLLEGE STATION
State	:	TX
Zip	:	77845-8963
Country	:	US
Telephone Number	:	979-207-6400
Fax Number	:

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

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	03/04/2025

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Directions to “ NICOLE RENE MARIETTA DO” Practice Location

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