Provider Demographics
NPI:1942748017
Name:FEDOTOWSKY, MARINA (CFNP)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:FEDOTOWSKY
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E 32ND ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-7287
Mailing Address - Country:US
Mailing Address - Phone:575-538-2981
Mailing Address - Fax:
Practice Address - Street 1:1511 S LIME ST
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-6207
Practice Address - Country:US
Practice Address - Phone:575-538-2981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-08
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM54159363LP2300X
OHAPRN.CNP.020037363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care