Provider Demographics
NPI:1932454907
Name:MARIANNE DECAIN TARRAZA NP, LLC
Entity Type:Organization
Organization Name:MARIANNE DECAIN TARRAZA NP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING BILLING REP
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:S
Authorized Official - Last Name:FOURNIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-312-1063
Mailing Address - Street 1:PO BOX 2328
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04116-2328
Mailing Address - Country:US
Mailing Address - Phone:207-312-1063
Mailing Address - Fax:207-375-5165
Practice Address - Street 1:1000 SHORE RD
Practice Address - Street 2:BUILDING #326
Practice Address - City:CAPE ELIZABETH
Practice Address - State:ME
Practice Address - Zip Code:04107-1916
Practice Address - Country:US
Practice Address - Phone:207-312-1063
Practice Address - Fax:207-375-5165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP81164163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, AdultGroup - Single Specialty