Provider Demographics
NPI:1063654358
Name:KING, MARJORIE WISE (IBCLC)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:WISE
Last Name:KING
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 DUNFRIES TER
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2415
Mailing Address - Country:US
Mailing Address - Phone:415-453-4035
Mailing Address - Fax:
Practice Address - Street 1:33 DUNFRIES TER
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2415
Practice Address - Country:US
Practice Address - Phone:415-453-4035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA26-4572386OtherEIN #26-4572386