MEDICARE: MARILYN P KING 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	363L00000X	Nurse Practitioner	0024164755	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	39703	OTHER	VA	OPTIMA

General Provider Information

NPI Number	:	1740286707
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARILYN P KING FNP

Provider Business Mailing Address
First Line	:	2500 E HUNT DR STE H-J
Second Line	:
City	:	SHOW LOW
State	:	AZ
Zip	:	85901-7954
Country	:	US
Telephone Number	:	928-537-6937
Fax Number	:	757-213-5701

Provider Business Practice Location Address
First Line	:	2500 E HUNT DR STE H-J
Second Line	:
City	:	SHOW LOW
State	:	AZ
Zip	:	85901-7954
Country	:	US
Telephone Number	:	928-537-6937
Fax Number	:	928-537-8798

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

Provider Enumeration Date	:	06/24/2005
Last Update Date	:	12/30/2021

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Directions to “ MARILYN P KING FNP” Practice Location

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