Provider Demographics
NPI:1720556855
Name:COMBS, MARLEEN JANNETT (FNP)
Entity Type:Individual
Prefix:
First Name:MARLEEN
Middle Name:JANNETT
Last Name:COMBS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2103
Mailing Address - Country:US
Mailing Address - Phone:318-698-3291
Mailing Address - Fax:318-698-3293
Practice Address - Street 1:909 OLIVE ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2103
Practice Address - Country:US
Practice Address - Phone:318-698-3291
Practice Address - Fax:318-698-3293
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-07
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP135256363LF0000X
LAAP09792363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2493116Medicaid