Provider Demographics
NPI:1306297544
Name:WARREN, MARQUETTA
Entity type:Individual
Prefix:
First Name:MARQUETTA
Middle Name:
Last Name:WARREN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:834 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-3317
Mailing Address - Country:US
Mailing Address - Phone:517-802-8009
Mailing Address - Fax:517-483-2533
Practice Address - Street 1:834 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-3317
Practice Address - Country:US
Practice Address - Phone:517-802-8009
Practice Address - Fax:517-483-2533
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI812710134251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health