Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363L00000X | Nurse Practitioner | 28250 | TN |
Y | 363LC0200X | Nurse Practitioner - Critical Care Medicine | 28250 | TN |
NPI | 1225640980 |
---|---|
Provider Name | Amanda Rae Marshall |
First Address | Lafayette, LA 70508-3870 |
Second Address | Bristol, TN 37620-7453 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/08/2020 |
Last Update Date | 14/07/2021 |