Provider Demographics
NPI:1114500170
Name:HARTMANN, MARLA MAE
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:MAE
Last Name:HARTMANN
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 1:28799 KORONIS DR
Mailing Address - Street 2:
Mailing Address - City:PAYNESVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56362-9331
Mailing Address - Country:US
Mailing Address - Phone:320-293-6705
Mailing Address - Fax:
Practice Address - Street 1:28799 KORONIS DR
Practice Address - Street 2:
Practice Address - City:PAYNESVILLE
Practice Address - State:MN
Practice Address - Zip Code:56362-9331
Practice Address - Country:US
Practice Address - Phone:320-293-6705
Practice Address - Fax:320-243-4777
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1106879Other245D