Provider Demographics
NPI:1801266572
Name:VAN TASSELL, MARLA JEAN (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:MARLA
Middle Name:JEAN
Last Name:VAN TASSELL
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 SHOUP AVE W STE B
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5042
Mailing Address - Country:US
Mailing Address - Phone:208-814-9100
Mailing Address - Fax:
Practice Address - Street 1:414 SHOUP AVE W STE B
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5042
Practice Address - Country:US
Practice Address - Phone:208-814-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1662A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health