Provider Demographics
NPI:1184864043
Name:JIM, MARLA D (RN)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:D
Last Name:JIM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MARLA
Other - Middle Name:D
Other - Last Name:HOWE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 3338
Mailing Address - Street 2:
Mailing Address - City:TOHAJIILEE
Mailing Address - State:NM
Mailing Address - Zip Code:87026-3338
Mailing Address - Country:US
Mailing Address - Phone:505-908-2307
Mailing Address - Fax:505-908-2310
Practice Address - Street 1:129 MEDICINE HORSE DRIVE
Practice Address - Street 2:
Practice Address - City:CANONCITO
Practice Address - State:NM
Practice Address - Zip Code:87026
Practice Address - Country:US
Practice Address - Phone:505-908-2307
Practice Address - Fax:505-908-2310
Is Sole Proprietor?:No
Enumeration Date:2009-03-04
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRN-69198163WC1500X
NMRN69198163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1194738328OtherNPI
NM30852081Medicaid
1194738328OtherNPI