Provider Demographics
NPI:1245563543
Name:MARSHALL, MICHAEL (APRN, PMHNP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:APRN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 E BROCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-3611
Mailing Address - Country:US
Mailing Address - Phone:909-328-1830
Mailing Address - Fax:
Practice Address - Street 1:1030 E BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-3611
Practice Address - Country:US
Practice Address - Phone:909-328-1830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-17
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA679231163W00000X
CA95028122363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
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