Provider Demographics
NPI:1629325451
Name:MOLINA, MARISSA MARIE
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:MARIE
Last Name:MOLINA
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:PO BOX 78
Mailing Address - Street 2:
Mailing Address - City:PERIDOT
Mailing Address - State:AZ
Mailing Address - Zip Code:85542-0078
Mailing Address - Country:US
Mailing Address - Phone:928-475-4323
Mailing Address - Fax:
Practice Address - Street 1:307 RAINBOW CITY CIRCLE
Practice Address - Street 2:
Practice Address - City:BYLAS
Practice Address - State:AZ
Practice Address - Zip Code:85530
Practice Address - Country:US
Practice Address - Phone:928-475-4076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant