Provider Demographics
NPI:1366829954
Name:KENYON, MARISSA CARR (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:CARR
Last Name:KENYON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:MARISSA
Other - Middle Name:LAUREN
Other - Last Name:CARR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:45511 LOUISE CT
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:MI
Mailing Address - Zip Code:48317-5782
Mailing Address - Country:US
Mailing Address - Phone:586-567-6664
Mailing Address - Fax:
Practice Address - Street 1:22101 MOROSS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2148
Practice Address - Country:US
Practice Address - Phone:313-343-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-03
Last Update Date:2015-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007066363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant