Provider Demographics
NPI:1811903784
Name:MARVICSIN, DONNA JEAN (NP)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:JEAN
Last Name:MARVICSIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 W 13 MILE RD
Mailing Address - Street 2:SUITE 707
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6770
Mailing Address - Country:US
Mailing Address - Phone:248-551-0487
Mailing Address - Fax:248-551-3696
Practice Address - Street 1:3535 W 13 MILE RD
Practice Address - Street 2:SUITE 707
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6770
Practice Address - Country:US
Practice Address - Phone:248-551-0487
Practice Address - Fax:248-551-3696
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704135783363LP0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4578770Medicaid
MI500F318190OtherBCBSM