Provider Demographics
NPI:1336349133
Name:LOTT, MARIAN VANITA (CNM)
Entity Type:Individual
Prefix:MS
First Name:MARIAN
Middle Name:VANITA
Last Name:LOTT
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:583 SUMMERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-5239
Mailing Address - Country:US
Mailing Address - Phone:707-539-1544
Mailing Address - Fax:707-539-0686
Practice Address - Street 1:5195 JIMMY CARTER BLVD
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-1649
Practice Address - Country:US
Practice Address - Phone:470-514-5818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPN001112363LX0001X, 367A00000X
GARN282818367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANMW012750Medicaid
11982826OtherCAQH
CANMW012750Medicaid