Provider Demographics
NPI:1215633474
Name:MARSHALL, AMBER DETRI (LPN)
Entity type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:DETRI
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:AMBER
Other - Middle Name:DETRI
Other - Last Name:DEATON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:6320 W HICKORY HILL DR
Mailing Address - Street 2:
Mailing Address - City:NORTH VERNON
Mailing Address - State:IN
Mailing Address - Zip Code:47265-7553
Mailing Address - Country:US
Mailing Address - Phone:812-558-9016
Mailing Address - Fax:
Practice Address - Street 1:357 TANGER BLVD STE 215
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-3597
Practice Address - Country:US
Practice Address - Phone:812-558-9016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN27065467A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse