Provider Demographics
NPI:1508363961
Name:WHITE, MARISSA (CNP)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22021 ECORSE RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-1847
Mailing Address - Country:US
Mailing Address - Phone:313-291-4444
Mailing Address - Fax:313-291-7540
Practice Address - Street 1:29911 6 MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-3603
Practice Address - Country:US
Practice Address - Phone:734-513-1600
Practice Address - Fax:734-513-1623
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI47044299632363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner