Provider Demographics
NPI:1871636878
Name:WORTMAN, MARILYN C (RN)
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:C
Last Name:WORTMAN
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 1:1629 WOODLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-2025
Mailing Address - Country:US
Mailing Address - Phone:731-285-7311
Mailing Address - Fax:731-285-2610
Practice Address - Street 1:1629 WOODLAWN AVE
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024
Practice Address - Country:US
Practice Address - Phone:731-285-7311
Practice Address - Fax:731-285-2610
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000030519163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse