Provider Demographics
NPI:1245787399
Name:PRAAY, MARLEEN MARIE
Entity Type:Individual
Prefix:
First Name:MARLEEN
Middle Name:MARIE
Last Name:PRAAY
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 1:5601 DOMINGO RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-1610
Mailing Address - Country:US
Mailing Address - Phone:505-268-5295
Mailing Address - Fax:
Practice Address - Street 1:5601 DOMINGO RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1610
Practice Address - Country:US
Practice Address - Phone:505-268-5295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMB9311Medicaid