Provider Demographics
NPI:1104177989
Name:MACEDO, MARISSA CHRISTINE (NNP)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:CHRISTINE
Last Name:MACEDO
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:CHRISTINE
Other - Last Name:BURCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NNP
Mailing Address - Street 1:2241 LLOYD CENTER
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-8122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-20
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201250151NP363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care