Provider Demographics
NPI:1427375997
Name:CROWTHER, MARILYN RAE
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:RAE
Last Name:CROWTHER
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 1:34852 363RD PL
Mailing Address - Street 2:
Mailing Address - City:AITKIN
Mailing Address - State:MN
Mailing Address - Zip Code:56431-5729
Mailing Address - Country:US
Mailing Address - Phone:218-927-2755
Mailing Address - Fax:
Practice Address - Street 1:34852 363RD PL
Practice Address - Street 2:ROCKY RIDGE AFC
Practice Address - City:AITKIN
Practice Address - State:MN
Practice Address - Zip Code:56431-5729
Practice Address - Country:US
Practice Address - Phone:218-927-2755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1052834-1-AFC171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor