Provider Demographics
NPI:1841318060
Name:YOUNGER, MARYANNA DORA
Entity type:Individual
Prefix:
First Name:MARYANNA
Middle Name:DORA
Last Name:YOUNGER
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 274
Mailing Address - Street 2:
Mailing Address - City:TULAROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88352-0274
Mailing Address - Country:US
Mailing Address - Phone:505-585-2761
Mailing Address - Fax:
Practice Address - Street 1:168 DERBYSHIRE RD
Practice Address - Street 2:
Practice Address - City:TULAROSA
Practice Address - State:NM
Practice Address - Zip Code:88352-0274
Practice Address - Country:US
Practice Address - Phone:505-585-2761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator