Provider Demographics
NPI:1366682700
Name:ROSEBOOM, MARJORIE STEPHANIE (FNP)
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:STEPHANIE
Last Name:ROSEBOOM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 GAUSE BLVD E
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-4149
Mailing Address - Country:US
Mailing Address - Phone:985-639-3777
Mailing Address - Fax:985-639-3725
Practice Address - Street 1:2750 GAUSE BLVD E
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-4149
Practice Address - Country:US
Practice Address - Phone:985-639-3777
Practice Address - Fax:985-639-3725
Is Sole Proprietor?:No
Enumeration Date:2009-02-25
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007497363LF0000X
LAAP08230363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02907034Medicaid
LA2398555Medicaid
LA432361YH3UMedicare PIN