Provider Demographics
NPI:1457755084
Name:CLEGG, MARIANNE
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
Last Name:CLEGG
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:PO BOX 1617
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:CO
Mailing Address - Zip Code:80549-8003
Mailing Address - Country:US
Mailing Address - Phone:907-619-9150
Mailing Address - Fax:
Practice Address - Street 1:7704 FOURTH
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:CO
Practice Address - Zip Code:80549
Practice Address - Country:US
Practice Address - Phone:907-619-9150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-10
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK7154164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse