Provider Demographics
NPI:1306201520
Name:ROBERTS, MARISSA (APRN-NP)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:APRN-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 BROADWAY STE B8
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-8193
Mailing Address - Country:US
Mailing Address - Phone:941-777-4542
Mailing Address - Fax:239-579-6807
Practice Address - Street 1:3900 BROADWAY STE A-14
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-8193
Practice Address - Country:US
Practice Address - Phone:941-777-4542
Practice Address - Fax:239-579-6807
Is Sole Proprietor?:No
Enumeration Date:2015-12-16
Last Update Date:2024-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9451478363L00000X, 363LF0000X
KY3009938363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019898000Medicaid