Provider Demographics
NPI:1073291241
Name:MARSHALL, CHRISTENA R
Entity Type:Individual
Prefix:
First Name:CHRISTENA
Middle Name:R
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19724 MOROSS RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-1170
Mailing Address - Country:US
Mailing Address - Phone:586-676-8337
Mailing Address - Fax:
Practice Address - Street 1:21172 VERMANDER AVE
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48035-3576
Practice Address - Country:US
Practice Address - Phone:586-224-2550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-07
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 302R00000X
MI374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No251S00000XAgenciesCommunity/Behavioral Health
No374U00000XNursing Service Related ProvidersHome Health Aide