Provider Demographics
NPI:1700220100
Name:JOHNSEN, MALISSA MARIE (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:MALISSA
Middle Name:MARIE
Last Name:JOHNSEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:MALISSA
Other - Middle Name:MARIE
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN
Mailing Address - Street 1:6 HARRISON CT
Mailing Address - Street 2:
Mailing Address - City:YARMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04096-1543
Mailing Address - Country:US
Mailing Address - Phone:503-739-5900
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3175
Practice Address - Country:US
Practice Address - Phone:207-662-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-29
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERNA203035367500000X
OR201340764RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse