Provider Demographics
NPI:1912405531
Name:CATRINE, MARYANNA KATHRYN
Entity type:Individual
Prefix:
First Name:MARYANNA
Middle Name:KATHRYN
Last Name:CATRINE
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 1:561 VALLEY VIEW PT
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-9099
Mailing Address - Country:US
Mailing Address - Phone:937-422-3449
Mailing Address - Fax:
Practice Address - Street 1:561 VALLEY VIEW PT
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-9099
Practice Address - Country:US
Practice Address - Phone:937-422-3449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
OH50.007758RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHIEDAN6392435OtherANTHEM BLUECROSS BLUESHIELD