Provider Demographics
NPI:1437890878
Name:EARLY, MARISSA
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:EARLY
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 1:5510 RAINTREE TRL
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-3821
Mailing Address - Country:US
Mailing Address - Phone:619-997-6053
Mailing Address - Fax:
Practice Address - Street 1:450 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801-3383
Practice Address - Country:US
Practice Address - Phone:407-930-9551
Practice Address - Fax:407-871-9240
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9774719174400000X, 172V00000X
FLFB9774719363L00000X, 363LF0000X
CA9774719101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No174400000XOther Service ProvidersSpecialist
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No172V00000XOther Service ProvidersCommunity Health Worker
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9439937OtherFBN
CA114301OtherDEPARTMENT OF CONSUMER AFFAIRS
FL9774719OtherDPBR
CA114301OtherDCABP