Provider Demographics
NPI:1730873753
Name:MARSHALL, TARENA (LAT, ATC)
Entity type:Individual
Prefix:
First Name:TARENA
Middle Name:
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 FAITH LN
Mailing Address - Street 2:
Mailing Address - City:MENDENHALL
Mailing Address - State:MS
Mailing Address - Zip Code:39114-5831
Mailing Address - Country:US
Mailing Address - Phone:601-382-5170
Mailing Address - Fax:
Practice Address - Street 1:403 MAIN ST
Practice Address - Street 2:
Practice Address - City:GRAMBLING
Practice Address - State:LA
Practice Address - Zip Code:71245-2715
Practice Address - Country:US
Practice Address - Phone:601-382-5170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA320938207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine