Basic Information
| Provider Information | |||||||||
| NPI: | 1225046394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POKRIEFKA | ||||||||
| FirstName: | MARINA | ||||||||
| MiddleName: | VICINI | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CNS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VICINI | ||||||||
| OtherFirstName: | MARINA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CNS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12850 FOUNTAIN SQ | ||||||||
| Address2: | STE. 106 | ||||||||
| City: | DAVISBURG | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483502552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486346303 | ||||||||
| FaxNumber: | 2486341746 | ||||||||
| Practice Location | |||||||||
| Address1: | 12850 FOUNTAIN SQ | ||||||||
| Address2: | STE. 106 | ||||||||
| City: | DAVISBURG | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483502552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486346303 | ||||||||
| FaxNumber: | 2486341746 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0807X | 4704115134 | MI | X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Child & Adolescent | 364SP0809X | 4704115134 | MI | X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult |
No ID Information.