Provider Demographics
NPI:1104714237
Name:NEEDLEMAN, MARISSA KATE
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:KATE
Last Name:NEEDLEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 SHELDON WOODS RD
Mailing Address - Street 2:
Mailing Address - City:SHELDON
Mailing Address - State:VT
Mailing Address - Zip Code:05483-8315
Mailing Address - Country:US
Mailing Address - Phone:802-309-3345
Mailing Address - Fax:
Practice Address - Street 1:133 FAIRFIELD ST
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-1726
Practice Address - Country:US
Practice Address - Phone:892-524-1232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-26
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0550031821363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical