Provider Demographics
NPI:1043048069
Name:DOUGLAS, MARLA MONIQUE
Entity type:Individual
Prefix:
First Name:MARLA
Middle Name:MONIQUE
Last Name:DOUGLAS
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 1:200 FOREST VLG APT 6
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-2855
Mailing Address - Country:US
Mailing Address - Phone:540-681-0038
Mailing Address - Fax:
Practice Address - Street 1:200 FOREST VLG APT 6
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-2855
Practice Address - Country:US
Practice Address - Phone:540-681-0038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1401181727376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide