Provider Demographics
NPI:1598179194
Name:PHILLIPS, MARISSA KAYANN
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:KAYANN
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7084 SE CYPRESS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97267-3329
Mailing Address - Country:US
Mailing Address - Phone:503-735-5827
Mailing Address - Fax:
Practice Address - Street 1:3716 SE INTERNATIONAL WAY
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-6001
Practice Address - Country:US
Practice Address - Phone:503-659-0073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19368174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist