Provider Demographics
NPI:1689932360
Name:WALLACE, MARISSA LEANNE (NP)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:LEANNE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3078 ROUTE 9W
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEW WINDSOR
Mailing Address - State:NY
Mailing Address - Zip Code:12553
Mailing Address - Country:US
Mailing Address - Phone:845-561-3310
Mailing Address - Fax:845-561-8728
Practice Address - Street 1:3078 ROUTE 9W STE 100
Practice Address - Street 2:
Practice Address - City:NEW WINDSOR
Practice Address - State:NY
Practice Address - Zip Code:12553-6751
Practice Address - Country:US
Practice Address - Phone:845-561-3310
Practice Address - Fax:845-561-8728
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY653689-1163W00000X
NYF308236363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse