Provider Demographics
NPI:1689058463
Name:SMITT, MARISA (CNP)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:SMITT
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:L
Other - Last Name:JAWORSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:29275 NORTHWESTERN HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-5700
Mailing Address - Country:US
Mailing Address - Phone:248-784-3667
Mailing Address - Fax:248-869-3982
Practice Address - Street 1:29275 NORTHWESTERN HWY STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-5700
Practice Address - Country:US
Practice Address - Phone:248-784-3667
Practice Address - Fax:248-869-3982
Is Sole Proprietor?:No
Enumeration Date:2015-07-12
Last Update Date:2024-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH17658363LF0000X
MI4704283890363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0140037Medicaid
OHH382570Medicare PIN