Provider Demographics
NPI:1629060835
Name:NISHITANI, MARILYN (CFNP)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:NISHITANI
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5010
Mailing Address - Country:US
Mailing Address - Phone:575-627-4200
Mailing Address - Fax:575-627-4212
Practice Address - Street 1:1112 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5010
Practice Address - Country:US
Practice Address - Phone:575-627-4200
Practice Address - Fax:575-627-4212
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR35362363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMS4973Medicaid
NMNMA103066Medicare PIN
NM348413201Medicare ID - Type Unspecified
S51064Medicare UPIN