Provider Demographics
NPI:1457828717
Name:VILLAFUERTE, MARISSA (ATC)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:VILLAFUERTE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5804 S 140TH AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-2845
Mailing Address - Country:US
Mailing Address - Phone:309-531-7296
Mailing Address - Fax:
Practice Address - Street 1:5804 S 140TH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-2845
Practice Address - Country:US
Practice Address - Phone:309-531-7296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer