Provider Demographics
NPI:1679029094
Name:SUMANO CHAMPLIN, MARYLYN (RN)
Entity Type:Individual
Prefix:
First Name:MARYLYN
Middle Name:
Last Name:SUMANO CHAMPLIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 I AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-2043
Mailing Address - Country:US
Mailing Address - Phone:541-962-0162
Mailing Address - Fax:541-962-0119
Practice Address - Street 1:1101 I AVE
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-2043
Practice Address - Country:US
Practice Address - Phone:541-962-0162
Practice Address - Fax:541-962-0119
Is Sole Proprietor?:No
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201505941RN163W00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No172V00000XOther Service ProvidersCommunity Health Worker