Provider Demographics
NPI:1306715511
Name:LANDRUM, MARISSA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:LANDRUM
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 1:17058 PALM RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-8846
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 REYNOIR ST
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39530-4130
Practice Address - Country:US
Practice Address - Phone:228-432-1571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-04
Last Update Date:2025-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS7118225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant