Basic Information
| Provider Information | |||||||||
| NPI: | 1356370993 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARMORINE | ||||||||
| FirstName: | KATHLEEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | HIGHWAY 1 | ||||||||
| Address2: | BOX 497 | ||||||||
| City: | RED LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566710497 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | HIGHWAY 1 | ||||||||
| Address2: | BOX 497 | ||||||||
| City: | RED LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566710497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186793912 | ||||||||
| FaxNumber: | 2186790181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 11/08/2007 | ||||||||
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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 | 363LF0000X | R 138537-1 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 387K5MA | 01 | MN | BC/BS OF MN | OTHER |