Provider Demographics
NPI:1437653870
Name:SMALL, MARISA GAYLE (FNP-C)
Entity Type:Individual
Prefix:MS
First Name:MARISA
Middle Name:GAYLE
Last Name:SMALL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:266 SUMMIT CIR
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-7443
Mailing Address - Country:US
Mailing Address - Phone:580-230-1542
Mailing Address - Fax:
Practice Address - Street 1:900 N ARMSTRONG AVE
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-2230
Practice Address - Country:US
Practice Address - Phone:903-465-2440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX717274363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily