Provider Demographics
NPI:1558952911
Name:RUSSO, MARISSA (NP)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13809 HILL ST
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-5328
Mailing Address - Country:US
Mailing Address - Phone:315-546-5184
Mailing Address - Fax:
Practice Address - Street 1:8712 LINDHOLM DR STE 302
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-1872
Practice Address - Country:US
Practice Address - Phone:704-997-6530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCF01210887363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner