Basic Information
| Provider Information | |||||||||
| NPI: | 1407855067 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARZELL | ||||||||
| FirstName: | JEANNE | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | CNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1067 | ||||||||
| Address2: | |||||||||
| City: | MARTINSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254021067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042637023 | ||||||||
| FaxNumber: | 3042640508 | ||||||||
| Practice Location | |||||||||
| Address1: | 99 TAVERN RD | ||||||||
| Address2: | |||||||||
| City: | MARTINSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254012890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042637023 | ||||||||
| FaxNumber: | 3042640508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2005 | ||||||||
| LastUpdateDate: | 05/15/2013 | ||||||||
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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 | 163WP0809X | 50409 | WV | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult |
ID Information
| ID | Type | State | Issuer | Description | 3810000518 | 05 | WV | MEDICAID |