Provider Demographics
NPI:1831504364
Name:COMBELLICK, MARJORIE (MSN, AGNPC, PMHNPBC)
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:
Last Name:COMBELLICK
Suffix:
Gender:F
Credentials:MSN, AGNPC, PMHNPBC
Other - Prefix:
Other - First Name:MARJORIE
Other - Middle Name:
Other - Last Name:DESTEFANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, AGNPC, PMHNPBC
Mailing Address - Street 1:109 BETA DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-3923
Mailing Address - Country:US
Mailing Address - Phone:317-519-6558
Mailing Address - Fax:
Practice Address - Street 1:1701 MERCY HEALTH PL
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45237-6147
Practice Address - Country:US
Practice Address - Phone:513-853-8520
Practice Address - Fax:513-442-7695
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004948A363LA2200X, 363LG0600X, 363LP2300X, 363LP0808X
VA0024185727363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201243060Medicaid