Provider Demographics
NPI:1356370993
Name:MARMORINE, KATHLEEN
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MARMORINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HIGHWAY 1
Mailing Address - Street 2:BOX 497
Mailing Address - City:RED LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56671-0497
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:HIGHWAY 1
Practice Address - Street 2:BOX 497
Practice Address - City:RED LAKE
Practice Address - State:MN
Practice Address - Zip Code:56671-0497
Practice Address - Country:US
Practice Address - Phone:218-679-3912
Practice Address - Fax:218-679-0181
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 138537-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN387K5MAOtherBC/BS OF MN
MN387K5MAOtherBC/BS OF MN
MNQ16268Medicare UPIN