Provider Demographics
NPI:1780458299
Name:VESCOVO, MARIANNA RUTHERFORD
Entity type:Individual
Prefix:
First Name:MARIANNA
Middle Name:RUTHERFORD
Last Name:VESCOVO
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 1:4760 LINDA LN
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-2512
Mailing Address - Country:US
Mailing Address - Phone:901-428-5194
Mailing Address - Fax:
Practice Address - Street 1:7205 WOLF RIVER BLVD STE 155
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1758
Practice Address - Country:US
Practice Address - Phone:901-322-7020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN664256220247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other