Provider Demographics
NPI:1629704929
Name:ONTIS, MARISSA ANNE (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:ANNE
Last Name:ONTIS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:ANNE
Other - Last Name:DELP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:709 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:IL
Mailing Address - Zip Code:62012-1045
Mailing Address - Country:US
Mailing Address - Phone:618-623-2836
Mailing Address - Fax:
Practice Address - Street 1:400 MAPLE SUMMIT RD STE 200
Practice Address - Street 2:
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052-2028
Practice Address - Country:US
Practice Address - Phone:618-498-8011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209025582363LF0000X
IL209.025582207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily