Provider Demographics
NPI:1972552578
Name:KOLLER, MARILYN A (APRN, BCADM, CDE)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:A
Last Name:KOLLER
Suffix:
Gender:F
Credentials:APRN, BCADM, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9165 W THUNDERBIRD RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4847
Mailing Address - Country:US
Mailing Address - Phone:623-583-5150
Mailing Address - Fax:623-523-6594
Practice Address - Street 1:9165 W THUNDERBIRD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4847
Practice Address - Country:US
Practice Address - Phone:623-583-5150
Practice Address - Fax:623-523-6594
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN097071364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ106144Medicare PIN
AZZ106143Medicare PIN
AZQ54413Medicare UPIN