Provider Demographics
NPI:1275068660
Name:MAEDER, MARISSA NICOLE
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:NICOLE
Last Name:MAEDER
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 1:205 S 6TH ST
Mailing Address - Street 2:PO BOX 99
Mailing Address - City:MALTA
Mailing Address - State:IL
Mailing Address - Zip Code:60150-9703
Mailing Address - Country:US
Mailing Address - Phone:815-761-8707
Mailing Address - Fax:
Practice Address - Street 1:205 S 6TH ST
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:IL
Practice Address - Zip Code:60150-9703
Practice Address - Country:US
Practice Address - Phone:815-761-8707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other