Provider Demographics
NPI:1851324255
Name:LETELLIER, MARIAN J (NP)
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:J
Last Name:LETELLIER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 N CENTRAL AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2914
Mailing Address - Country:US
Mailing Address - Phone:602-685-6000
Mailing Address - Fax:602-302-7925
Practice Address - Street 1:4201 N 16TH ST STE 250
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5375
Practice Address - Country:US
Practice Address - Phone:602-685-6000
Practice Address - Fax:602-248-8936
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN085152363LP0808X
AZAP1242363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ553679Medicaid
AZ553679Medicaid