Provider Demographics
NPI:1861174054
Name:MAANUM, MARLIE MAE
Entity type:Individual
Prefix:
First Name:MARLIE
Middle Name:MAE
Last Name:MAANUM
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 1:16 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAMOURE
Mailing Address - State:ND
Mailing Address - Zip Code:58458-7412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1420 9TH ST E STE 401
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-3381
Practice Address - Country:US
Practice Address - Phone:701-658-7015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist