Provider Demographics
NPI:1124063409
Name:HABTEMARIAM, MARYON JOYCE (ARNP)
Entity type:Individual
Prefix:MRS
First Name:MARYON
Middle Name:JOYCE
Last Name:HABTEMARIAM
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 N PERSHING ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67220-2909
Mailing Address - Country:US
Mailing Address - Phone:316-250-6678
Mailing Address - Fax:
Practice Address - Street 1:1515 S CLIFTON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-2900
Practice Address - Country:US
Practice Address - Phone:316-687-9961
Practice Address - Fax:316-687-6561
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS74269363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS161050Medicare ID - Type Unspecified