Provider Demographics
NPI:1477286896
Name:BLOCK, MARISSA
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:BLOCK
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 1:822 E WASHINGTON AVE APT 1119
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-6515
Mailing Address - Country:US
Mailing Address - Phone:414-813-1102
Mailing Address - Fax:
Practice Address - Street 1:822 E WASHINGTON AVE APT 1119
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-6515
Practice Address - Country:US
Practice Address - Phone:414-813-1102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-04
Last Update Date:2022-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program