Provider Demographics
NPI:1750681193
Name:BRUZZONE, MARISA (LMP)
Entity Type:Individual
Prefix:MS
First Name:MARISA
Middle Name:
Last Name:BRUZZONE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14210 79TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-0712
Mailing Address - Country:US
Mailing Address - Phone:206-734-6566
Mailing Address - Fax:206-905-2994
Practice Address - Street 1:11417 124TH AVE NE STE 104
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-4677
Practice Address - Country:US
Practice Address - Phone:206-734-6566
Practice Address - Fax:206-275-4876
Is Sole Proprietor?:No
Enumeration Date:2010-11-02
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00021645174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist