Provider Demographics
NPI:1073917258
Name:MYRES, MARISSA CHRISTINE (APRN,CNS)
Entity Type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:CHRISTINE
Last Name:MYRES
Suffix:
Gender:F
Credentials:APRN,CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3308 W CHARTWELL RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-2322
Mailing Address - Country:US
Mailing Address - Phone:309-691-7640
Mailing Address - Fax:309-691-7643
Practice Address - Street 1:3308 W CHARTWELL RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2322
Practice Address - Country:US
Practice Address - Phone:309-691-7640
Practice Address - Fax:309-691-7643
Is Sole Proprietor?:No
Enumeration Date:2014-10-16
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.385496163W00000X
IL209.012031364S00000X
IL209012031364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
No163W00000XNursing Service ProvidersRegistered Nurse
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist