Provider Demographics
NPI:1649252438
Name:PRINCE, MARITA JOAN (DNP)
Entity type:Individual
Prefix:MRS
First Name:MARITA
Middle Name:JOAN
Last Name:PRINCE
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4313 FAIRWAY PATH
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-1455
Mailing Address - Country:US
Mailing Address - Phone:573-855-2576
Mailing Address - Fax:
Practice Address - Street 1:36065 SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-5060
Practice Address - Country:US
Practice Address - Phone:301-295-9004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN132098163W00000X, 390200000X
AZ241332363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program