Provider Demographics
NPI:1689264475
Name:MUELLER, MARISSA ROSE (FNP-C)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:ROSE
Last Name:MUELLER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-3202
Practice Address - Street 1:2005 PISGAH CHURCH RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27455-3309
Practice Address - Country:US
Practice Address - Phone:336-716-9150
Practice Address - Fax:336-702-9166
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-25
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28224146A207Q00000X
TX1035440363LF0000X
NC5015781363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1831173707OtherCASH PAY PRACTIVE