Provider Demographics
NPI:1568618965
Name:NIESE, MARIAN JANE
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:JANE
Last Name:NIESE
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 1:6701 FORTUNA RD NW
Mailing Address - Street 2:WEST MESA HS
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-1306
Mailing Address - Country:US
Mailing Address - Phone:505-831-6903
Mailing Address - Fax:
Practice Address - Street 1:6701 FORTUNA RD NW
Practice Address - Street 2:WEST MESA HS
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87121-1306
Practice Address - Country:US
Practice Address - Phone:505-831-6903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC 4346235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNONE ASSIGNEDMedicaid