Provider Demographics
NPI:1891402830
Name:FORTUNA, MARISSA ANNE (MSN, FNP-C)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:ANNE
Last Name:FORTUNA
Suffix:
Gender:F
Credentials:MSN, FNP-C
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:
Other - Last Name:STAFFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, FNP-C
Mailing Address - Street 1:1850 E 53RD ST STE 2
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-2784
Mailing Address - Country:US
Mailing Address - Phone:563-359-4106
Mailing Address - Fax:
Practice Address - Street 1:1850 E 53RD ST STE 2
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-2784
Practice Address - Country:US
Practice Address - Phone:563-335-9410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-31
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA166951363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily