Provider Demographics
NPI:1477705614
Name:PEREZ, MARISA (RN, MSN, FNP)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:PEREZ
Suffix:
Gender:F
Credentials:RN, MSN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5574 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-2058
Mailing Address - Country:US
Mailing Address - Phone:219-980-0378
Mailing Address - Fax:
Practice Address - Street 1:4321 FIR ST
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-3049
Practice Address - Country:US
Practice Address - Phone:219-392-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28074874A163W00000X
IN71002794A363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN253370BMedicare PIN
INP00727373Medicare PIN