Provider Demographics
NPI:1568980779
Name:CLAY, MARLA JEAN (LPN)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:JEAN
Last Name:CLAY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MARLA
Other - Middle Name:JEAN
Other - Last Name:CLAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:1717 W. GLENDALE AVE. APT. 3011
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021
Mailing Address - Country:US
Mailing Address - Phone:602-461-5330
Mailing Address - Fax:
Practice Address - Street 1:1717 W. GLENDALE AVE. APT. 3011
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021
Practice Address - Country:US
Practice Address - Phone:602-461-5330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP046141164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty