Provider Demographics
NPI:1386190411
Name:OVERDUYN, MARNEE
Entity Type:Individual
Prefix:
First Name:MARNEE
Middle Name:
Last Name:OVERDUYN
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 1:7905 W USTICK RD
Mailing Address - Street 2:STE E
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5001
Mailing Address - Country:US
Mailing Address - Phone:208-322-6211
Mailing Address - Fax:208-322-6304
Practice Address - Street 1:7905 W USTICK RD
Practice Address - Street 2:STE E
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5001
Practice Address - Country:US
Practice Address - Phone:208-322-6211
Practice Address - Fax:208-322-6304
Is Sole Proprietor?:No
Enumeration Date:2016-08-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1447439674Medicaid