Basic Information
| Provider Information | |||||||||
| NPI: | 1336677624 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARINO | ||||||||
| FirstName: | WENDY | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | MSN, NP-BC, CORLN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 764 LAKELAND DRIVE | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019845160 | ||||||||
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| Practice Location | |||||||||
| Address1: | 764 LAKELAND DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019845516 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2017 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | MARI-5T0VNQ | MS | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.