1104345842 NPI number — ERICA GAIL MARRIOTT FNP-C

Table of content: ERICA GAIL MARRIOTT FNP-C (NPI 1104345842)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104345842 NPI number — ERICA GAIL MARRIOTT FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARRIOTT
Provider First Name:
ERICA
Provider Middle Name:
GAIL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LOVORN, HAYHURST BUCKNER MENDENHALL
Provider Other First Name:
ERICA
Provider Other Middle Name:
GAIL
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104345842
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1202 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLOW SPRINGS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65793-3588
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-469-1820
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1202 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLOW SPRINGS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65793-3588
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-469-1820
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/13/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  2003015908 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 2017035199 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2003015908 . This is a "MISSOURI STATE BOARD OF NURSING REGISTERED NURSE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: F09171097 . This is a "AMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICAN BOARD FAMILY NURSE PRACTITION" identifier . This identifiers is of the category "OTHER".




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