Provider Demographics
NPI:1235591769
Name:MOULTRIE, MARISSA MICHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:MICHELLE
Last Name:MOULTRIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 HOSPITAL CENTER BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-6202
Mailing Address - Country:US
Mailing Address - Phone:540-602-6500
Mailing Address - Fax:
Practice Address - Street 1:125 HOSPITAL CENTER BLVD STE 110
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-6202
Practice Address - Country:US
Practice Address - Phone:540-602-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2021-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101265808207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program