Provider Demographics
NPI:1891223111
Name:KOTTKE, MARLINE SHARON
Entity type:Individual
Prefix:
First Name:MARLINE
Middle Name:SHARON
Last Name:KOTTKE
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 1:1212 N CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-1552
Mailing Address - Country:US
Mailing Address - Phone:209-468-8661
Mailing Address - Fax:
Practice Address - Street 1:1212 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-1552
Practice Address - Country:US
Practice Address - Phone:209-468-8661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN198957164X00000X
CA198957164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No164X00000XNursing Service ProvidersLicensed Vocational Nurse