Provider Demographics
NPI:1801374889
Name:BOEDING, MARISSA (NP)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:BOEDING
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 1:127 BRODIA WAY
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-4919
Mailing Address - Country:US
Mailing Address - Phone:513-550-1376
Mailing Address - Fax:
Practice Address - Street 1:4150 CLEMENT ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94121-1563
Practice Address - Country:US
Practice Address - Phone:415-583-9564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95138897163WP0808X
CA95012839363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health