Provider Demographics
NPI:1235640509
Name:KENNELL, MARISSA ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:ANN
Last Name:KENNELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:ANN
Other - Last Name:PIERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:511 E GITTINGS ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-4332
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6701 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-6808
Practice Address - Country:US
Practice Address - Phone:443-849-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-13
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC06622363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant