Provider Demographics
NPI:1790345536
Name:BOTHA, MARCELLE (NP-C)
Entity Type:Individual
Prefix:
First Name:MARCELLE
Middle Name:
Last Name:BOTHA
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 1:1008 W 48TH ST
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-1243
Mailing Address - Country:US
Mailing Address - Phone:308-991-7494
Mailing Address - Fax:
Practice Address - Street 1:10 E 31ST ST
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-2908
Practice Address - Country:US
Practice Address - Phone:308-865-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE112804363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner