Provider Demographics
NPI:1073189429
Name:DICE, MARISSA NICOLE-VIVIAN (RN)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:NICOLE-VIVIAN
Last Name:DICE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1479 PUSHAW RD
Mailing Address - Street 2:
Mailing Address - City:GLENBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04401-1450
Mailing Address - Country:US
Mailing Address - Phone:207-446-5926
Mailing Address - Fax:
Practice Address - Street 1:489 STATE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6616
Practice Address - Country:US
Practice Address - Phone:207-973-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME390200000X
MERNA233043367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program