Provider Demographics
NPI:1609295534
Name:MENCIO, MARISSA ANNE (MD)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:ANNE
Last Name:MENCIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3024 BUSINESS PARK CIR
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3132
Mailing Address - Country:US
Mailing Address - Phone:615-239-2018
Mailing Address - Fax:
Practice Address - Street 1:3901 CENTRAL PIKE STE 351
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076
Practice Address - Country:US
Practice Address - Phone:615-889-8802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-08
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN61783208600000X, 208600000X
NY298487-1208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty