Provider Demographics
NPI:1720036965
Name:HARRIS, MARLENA JO (MSN,APRN,BC,CRNA)
Entity Type:Individual
Prefix:MRS
First Name:MARLENA
Middle Name:JO
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MSN,APRN,BC,CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 MACCORKLE AVE SE
Mailing Address - Street 2:CAMC
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1227
Mailing Address - Country:US
Mailing Address - Phone:304-388-6220
Mailing Address - Fax:
Practice Address - Street 1:128 1/2 EAST POINT DRIVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311
Practice Address - Country:US
Practice Address - Phone:304-925-2266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV42882363LF0000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810001280Medicaid
WVNP77621Medicare ID - Type Unspecified
WV3810001280Medicaid