Provider Demographics
NPI:1225483860
Name:BENGE, MARISSA MEDEROS (FNP)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:MEDEROS
Last Name:BENGE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3638 24TH ST
Mailing Address - Street 2:APT 2
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-3685
Mailing Address - Country:US
Mailing Address - Phone:985-264-0261
Mailing Address - Fax:
Practice Address - Street 1:2340 CLAY ST
Practice Address - Street 2:SUITE 600
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-1932
Practice Address - Country:US
Practice Address - Phone:415-674-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-02
Last Update Date:2017-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004182363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily