Provider Demographics
NPI:1740286707
Name:KING, MARILYN P (FNP)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:P
Last Name:KING
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 E HUNT DR STE H-J
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7954
Mailing Address - Country:US
Mailing Address - Phone:928-537-6937
Mailing Address - Fax:757-213-5701
Practice Address - Street 1:2500 E HUNT DR STE H-J
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7954
Practice Address - Country:US
Practice Address - Phone:928-537-6937
Practice Address - Fax:928-537-8798
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024164755363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA39703OtherOPTIMA
VA39703OtherOPTIMA
VA017583V25Medicare PIN
VAP27731Medicare UPIN