Provider Demographics
NPI:1275718744
Name:SANBORN, MARILYN ANNETTE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:ANNETTE
Last Name:SANBORN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6250 KINGBIRD DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43230
Mailing Address - Country:US
Mailing Address - Phone:614-353-0619
Mailing Address - Fax:614-245-8098
Practice Address - Street 1:6250 KINGBIRD DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43230
Practice Address - Country:US
Practice Address - Phone:614-353-0619
Practice Address - Fax:614-245-8098
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN106483164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2190883Medicaid