Provider Demographics
NPI:1700038353
Name:ATWATER, MARCELLA MASSENBURG (PMHCNS-BC)
Entity Type:Individual
Prefix:MS
First Name:MARCELLA
Middle Name:MASSENBURG
Last Name:ATWATER
Suffix:
Gender:F
Credentials:PMHCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 BOWLER DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-6311
Mailing Address - Country:US
Mailing Address - Phone:919-687-4013
Mailing Address - Fax:919-680-4010
Practice Address - Street 1:1008 BOWLER DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-6311
Practice Address - Country:US
Practice Address - Phone:919-687-4013
Practice Address - Fax:919-680-4010
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-15
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC069765163WP0809X
NC69765364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1700038353Medicaid
NC1700038353Medicaid