Provider Demographics
NPI:1174811624
Name:CHAN, MARJORIE M (NP)
Entity type:Individual
Prefix:MS
First Name:MARJORIE
Middle Name:M
Last Name:CHAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARJORIE
Other - Middle Name:S
Other - Last Name:MANZANILLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:3090 BRISTOL ST STE 200
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3061
Mailing Address - Country:US
Mailing Address - Phone:714-619-8777
Mailing Address - Fax:714-619-8770
Practice Address - Street 1:3090 BRISTOL ST STE 200
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-3061
Practice Address - Country:US
Practice Address - Phone:888-789-9585
Practice Address - Fax:562-803-4500
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20829363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner