Individual
MRS. MARINA DEATHERAGE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
146 E GENEVA SQ, LAKE GENEVA, WI 53147-9694
(262) 249-4660
Mailing address
146 E GENEVA SQ, LAKE GENEVA, WI 53147-9694
(262) 249-4660
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
10857-033
WI
363LF0000X
Family Nurse Practitioner
209020317
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100162164
—
WI
Enumeration date
12/05/2019
Last updated
11/30/2021
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