Provider Demographics
NPI:1619510237
Name:HARRISON, MARLENE RENITA
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:RENITA
Last Name:HARRISON
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 1:814 LINDSEY ST
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-3112
Mailing Address - Country:US
Mailing Address - Phone:336-280-1358
Mailing Address - Fax:336-347-0248
Practice Address - Street 1:814 LINDSEY ST
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-3112
Practice Address - Country:US
Practice Address - Phone:336-280-1358
Practice Address - Fax:336-347-0248
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-27
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-079-113311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home