Provider Demographics
NPI:1851836472
Name:REYNOSO, MARISSA (CRNA)
Entity Type:Individual
Prefix:MS
First Name:MARISSA
Middle Name:
Last Name:REYNOSO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3151 S ST APT 340
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-7075
Mailing Address - Country:US
Mailing Address - Phone:510-449-7738
Mailing Address - Fax:
Practice Address - Street 1:3138 CHIMNEY CT
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587-1650
Practice Address - Country:US
Practice Address - Phone:510-449-7738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-05
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000694367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered