Provider Demographics
NPI:1093820698
Name:DISSETTE, MARLENE (FNP, WHCNP)
Entity Type:Individual
Prefix:MS
First Name:MARLENE
Middle Name:
Last Name:DISSETTE
Suffix:
Gender:F
Credentials:FNP, WHCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 NE WEST DEVILS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97367-5131
Mailing Address - Country:US
Mailing Address - Phone:541-994-8911
Mailing Address - Fax:
Practice Address - Street 1:3015 NE WEST DEVILS LAKE RD
Practice Address - Street 2:
Practice Address - City:LINCOLN CITY
Practice Address - State:OR
Practice Address - Zip Code:97367-5131
Practice Address - Country:US
Practice Address - Phone:541-994-8911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200650009NP363LW0102X
OR200850011NP261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health