Provider Demographics
NPI:1851525703
Name:PFOHL, MARISSA SUE
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:SUE
Last Name:PFOHL
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 1:751 LOMBARDI CT
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-6798
Mailing Address - Country:US
Mailing Address - Phone:707-547-2222
Mailing Address - Fax:
Practice Address - Street 1:751 LOMBARDI CT
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-6798
Practice Address - Country:US
Practice Address - Phone:707-547-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-06
Last Update Date:2013-09-23
Deactivation Date:2010-07-21
Deactivation Code:
Reactivation Date:2013-09-20
Provider Licenses
StateLicense IDTaxonomies
CA23585363LF0000X
CA841336163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse