Provider Demographics
NPI:1023279205
Name:BOETTGER, MARIANNE L (RN, NP)
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:L
Last Name:BOETTGER
Suffix:
Gender:F
Credentials:RN, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4815 W MARKHAM ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-3866
Mailing Address - Country:US
Mailing Address - Phone:501-661-2000
Mailing Address - Fax:
Practice Address - Street 1:4815 W MARKHAM ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-3866
Practice Address - Country:US
Practice Address - Phone:501-661-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 149402-6363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN500004574Medicare PIN