Provider Demographics
NPI:1710750195
Name:MARSHALL, OCTAVIA SYMONE (NP-C)
Entity Type:Individual
Prefix:
First Name:OCTAVIA
Middle Name:SYMONE
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 RECA ST
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-5546
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27991 CENTER RIDGE RD
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-3902
Practice Address - Country:US
Practice Address - Phone:800-334-8603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANP001688363LF0000X
CA95027199363LF0000X
TX1140168363LF0000X
MS906173363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily