Provider Demographics
NPI:1114236916
Name:STEFANO, MARISSA
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:STEFANO
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 1:3625 S DECATUR BLVD
Mailing Address - Street 2:1097
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-5813
Mailing Address - Country:US
Mailing Address - Phone:720-252-9386
Mailing Address - Fax:
Practice Address - Street 1:3625 S DECATUR BLVD
Practice Address - Street 2:1097
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-5813
Practice Address - Country:US
Practice Address - Phone:720-252-9386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-28
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker