Provider Demographics
NPI:1578273892
Name:RAINEY, MARISA ALLYCE (APRN)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:ALLYCE
Last Name:RAINEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 W FAIRBANKS AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-4756
Mailing Address - Country:US
Mailing Address - Phone:321-843-5851
Mailing Address - Fax:321-842-1611
Practice Address - Street 1:1111 W FAIRBANKS AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-4756
Practice Address - Country:US
Practice Address - Phone:321-843-5851
Practice Address - Fax:321-842-1611
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-28
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11022212363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily