Provider Demographics
NPI:1235534421
Name:WRIGHT, MARISA (CLC, CD(DONA))
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:CLC, CD(DONA)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 BURLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-5427
Mailing Address - Country:US
Mailing Address - Phone:406-880-2320
Mailing Address - Fax:
Practice Address - Street 1:1925 BURLINGTON AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-5427
Practice Address - Country:US
Practice Address - Phone:406-880-2320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-30
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X
MT472020364174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No174N00000XOther Service ProvidersLactation Consultant, Non-RN