Provider Demographics
NPI:1699832048
Name:MARINO, MARY ELLEN (DOM,ND)
Entity Type:Individual
Prefix:DR
First Name:MARY ELLEN
Middle Name:
Last Name:MARINO
Suffix:
Gender:F
Credentials:DOM,ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RT 5 BOX 279A
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87506
Mailing Address - Country:US
Mailing Address - Phone:505-455-0005
Mailing Address - Fax:
Practice Address - Street 1:1925 ASPEN DR
Practice Address - Street 2:302 B
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-5459
Practice Address - Country:US
Practice Address - Phone:505-455-0005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM346171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNMOOR434OtherBLUE CROSS BLUE SHEILD