Provider Demographics
NPI:1790460632
Name:LYNCH, MARISSA
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:LYNCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2593 COUNTY ROAD M APT SUITE
Mailing Address - Street 2:
Mailing Address - City:BOSCOBEL
Mailing Address - State:WI
Mailing Address - Zip Code:53805-9517
Mailing Address - Country:US
Mailing Address - Phone:608-485-1352
Mailing Address - Fax:
Practice Address - Street 1:770 LINCOLN AVE STE 5
Practice Address - Street 2:
Practice Address - City:FENNIMORE
Practice Address - State:WI
Practice Address - Zip Code:53809-1563
Practice Address - Country:US
Practice Address - Phone:608-485-1352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14351363L00000X
IAA174764363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner