1831504364 NPI number — MARJORIE COMBELLICK MSN, AGNPC, PMHNPBC

Table of content: MARJORIE COMBELLICK MSN, AGNPC, PMHNPBC (NPI 1831504364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831504364 NPI number — MARJORIE COMBELLICK MSN, AGNPC, PMHNPBC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COMBELLICK
Provider First Name:
MARJORIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSN, AGNPC, PMHNPBC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DESTEFANO
Provider Other First Name:
MARJORIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSN, AGNPC, PMHNPBC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1831504364
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
109 BETA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70506-3923
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-519-6558
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 MERCY HEALTH PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45237-6147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-853-8520
Provider Business Practice Location Address Fax Number:
513-442-7695
Provider Enumeration Date:
06/23/2014

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: 363LA2200X , with the licence number:  71004948A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LG0600X , with the licence number: 71004948A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: 0024185727 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP2300X , with the licence number: 71004948A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: 71004948A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 201243060 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".