Provider Demographics
NPI:1639122682
Name:GUNDERSON, MARISSA (RN,APN C)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:GUNDERSON
Suffix:
Gender:F
Credentials:RN,APN C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 WOODMERE AVE
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-5636
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:572 COOKMAN AVE
Practice Address - Street 2:
Practice Address - City:ASBURY PARK
Practice Address - State:NJ
Practice Address - Zip Code:07712-7102
Practice Address - Country:US
Practice Address - Phone:732-774-6333
Practice Address - Fax:732-774-8083
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00021000363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJX5/19Medicaid
NJX5/19Medicaid
NJQ03711Medicare UPIN