Provider Demographics
NPI:1366007411
Name:NDUM, MARCELINE E
Entity Type:Individual
Prefix:
First Name:MARCELINE
Middle Name:E
Last Name:NDUM
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:PO BOX 746093
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6093
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:312-929-0373
Practice Address - Street 1:1036 N ARIZONA AVE
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-6600
Practice Address - Country:US
Practice Address - Phone:480-618-0027
Practice Address - Fax:520-300-8059
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-03
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ224902207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty