Provider Demographics
NPI:1124413323
Name:PODOLSKIY, MARINA N (ARNP/ CNM)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:N
Last Name:PODOLSKIY
Suffix:
Gender:F
Credentials:ARNP/ CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3231 S NATIONAL AVE STE 320
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-7304
Mailing Address - Country:US
Mailing Address - Phone:417-888-5611
Mailing Address - Fax:
Practice Address - Street 1:3231 S NATIONAL AVE STE 320
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7304
Practice Address - Country:US
Practice Address - Phone:417-888-5611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-03
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60863109367A00000X
MO2020026950367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WARN60025099OtherWA STATE DEPT OF HEALTH, RN LICENSE
CNM04878OtherAMERICAN MIDWIFERY CERTIFICATION BOARD (AMCB)
WA2108562Medicaid
WAAP60863109OtherWA STATE ARNP LICENSE