Basic Information
| Provider Information | |||||||||
| NPI: | 1992713887 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARRETT | ||||||||
| FirstName: | MARIANNE | ||||||||
| MiddleName: | KULESA | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5803 ARMY PENTAGON MF877B | ||||||||
| Address2: | DILORENZO TRICARE HEALTH CLINIC | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 20310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039148000 | ||||||||
| FaxNumber: | 7036421876 | ||||||||
| Practice Location | |||||||||
| Address1: | 5803 ARMY PENTAGON MF877B | ||||||||
| Address2: | DILORENZO TRICARE HEALTH CLINIC | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 203100001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039148000 | ||||||||
| FaxNumber: | 7036421876 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 05/07/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 0110001599 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.