Provider Demographics
NPI:1629114483
Name:BAKER, MARILYN GRACE (LVN)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:GRACE
Last Name:BAKER
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LVN
Mailing Address - Street 1:PO BOX 243
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96114-0243
Mailing Address - Country:US
Mailing Address - Phone:530-253-2186
Mailing Address - Fax:
Practice Address - Street 1:1445 BUNYAN RD
Practice Address - Street 2:SUITE B
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130-3142
Practice Address - Country:US
Practice Address - Phone:530-251-2608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN125227164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse