Provider Demographics
NPI:1275094294
Name:BLACKWELL, MARISSA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:
Last Name:BLACKWELL
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 1:1215 LEE ST. BOX 800394
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22908-0816
Mailing Address - Country:US
Mailing Address - Phone:434-924-5306
Mailing Address - Fax:434-982-1064
Practice Address - Street 1:1215 LEE ST. NEUROLOGY 800394
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-1544
Practice Address - Country:US
Practice Address - Phone:434-924-5306
Practice Address - Fax:434-982-1064
Is Sole Proprietor?:No
Enumeration Date:2019-03-31
Last Update Date:2023-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116038303390200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program