Provider Demographics
NPI:1659691491
Name:PAGE, MARISSA (NP)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:PAGE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:
Other - Last Name:KANTHAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:6 WELLNESS WAY STE 201
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2156
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:6 WELLNESS WAY STE 106
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2156
Practice Address - Country:US
Practice Address - Phone:518-782-3899
Practice Address - Fax:518-782-3884
Is Sole Proprietor?:No
Enumeration Date:2010-06-03
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF336183363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03273750Medicaid
NY03273750Medicaid