Provider Demographics
NPI:1376611863
Name:MARZELLA, KAREN (NURSE PRACTIONIER)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:MARZELLA
Suffix:
Gender:F
Credentials:NURSE PRACTIONIER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20952 E 12 MILE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3200
Mailing Address - Country:US
Mailing Address - Phone:586-771-4820
Mailing Address - Fax:586-771-6620
Practice Address - Street 1:130 TOWN CENTER DR STE 200
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-1744
Practice Address - Country:US
Practice Address - Phone:248-740-0670
Practice Address - Fax:248-740-0668
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704123587163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICB9133OtherRAILROAD MEDICARE
MI0P12960001Medicare PIN
MI0219690001Medicare NSC