Provider Demographics
NPI:1053848309
Name:MARINO, KIMBERLY MICHELLE (DNP)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:MICHELLE
Last Name:MARINO
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:MICHELLE
Other - Last Name:MARINO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DNP
Mailing Address - Street 1:4302 APPLE TREE LN
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-7401
Mailing Address - Country:US
Mailing Address - Phone:231-492-7290
Mailing Address - Fax:
Practice Address - Street 1:607 RANDOLPH ST STE 101
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2248
Practice Address - Country:US
Practice Address - Phone:231-251-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-17
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704214077363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily