Basic Information
| Provider Information | |||||||||
| NPI: | 1972552578 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOLLER | ||||||||
| FirstName: | MARILYN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | APRN, BCADM, CDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9165 W THUNDERBIRD RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235835150 | ||||||||
| FaxNumber: | 6235236594 | ||||||||
| Practice Location | |||||||||
| Address1: | 9165 W THUNDERBIRD RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235835150 | ||||||||
| FaxNumber: | 6235236594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 03/01/2011 | ||||||||
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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 | 364S00000X | RN097071 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |
No ID Information.