Provider Demographics
NPI:1679801062
Name:LEWIS, MARISSA JONES (BSN RN, RDH)
Entity Type:Individual
Prefix:MS
First Name:MARISSA
Middle Name:JONES
Last Name:LEWIS
Suffix:
Gender:F
Credentials:BSN RN, RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 MCDOWELL ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-4182
Mailing Address - Country:US
Mailing Address - Phone:912-424-9014
Mailing Address - Fax:
Practice Address - Street 1:2005 MCDOWELL ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-4182
Practice Address - Country:US
Practice Address - Phone:912-424-9014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-24
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FM003661124Q00000X
GA165342163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No124Q00000XDental ProvidersDental Hygienist