Provider Demographics
NPI:1538318993
Name:LEAVERSUCH, MARISSA ROSE (CPNP)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:ROSE
Last Name:LEAVERSUCH
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 BEACH STREET
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151
Mailing Address - Country:US
Mailing Address - Phone:781-289-5057
Mailing Address - Fax:781-289-4485
Practice Address - Street 1:280 BEACH STREET
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151
Practice Address - Country:US
Practice Address - Phone:781-289-5057
Practice Address - Fax:781-289-4485
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN260274363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics