Provider Demographics
NPI:1760636765
Name:LITTLE THUNDER, MARIETTA L (RN)
Entity Type:Individual
Prefix:
First Name:MARIETTA
Middle Name:L
Last Name:LITTLE THUNDER
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:PO BOX J
Mailing Address - Street 2:
Mailing Address - City:FORT YATES
Mailing Address - State:ND
Mailing Address - Zip Code:58538-0527
Mailing Address - Country:US
Mailing Address - Phone:701-854-8215
Mailing Address - Fax:701-854-3685
Practice Address - Street 1:N10 NORTH RIVER ROAD
Practice Address - Street 2:
Practice Address - City:FORT YATES
Practice Address - State:ND
Practice Address - Zip Code:58538-0527
Practice Address - Country:US
Practice Address - Phone:701-854-8215
Practice Address - Fax:701-854-3685
Is Sole Proprietor?:No
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR022653163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse