Provider Demographics
NPI:1629443023
Name:DISPENZA, MARISSA
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:DISPENZA
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 1:309 HAMPTON BLVD
Mailing Address - Street 2:
Mailing Address - City:GREECE
Mailing Address - State:NY
Mailing Address - Zip Code:14612-4238
Mailing Address - Country:US
Mailing Address - Phone:585-880-5595
Mailing Address - Fax:
Practice Address - Street 1:309 HAMPTON BLVD
Practice Address - Street 2:
Practice Address - City:GREECE
Practice Address - State:NY
Practice Address - Zip Code:14612-4238
Practice Address - Country:US
Practice Address - Phone:585-880-5595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY321583164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse