Provider Demographics
NPI:1891929329
Name:CARISSIMO, MARRA F (LMP)
Entity Type:Individual
Prefix:
First Name:MARRA
Middle Name:F
Last Name:CARISSIMO
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4402 N 34TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98407-4728
Mailing Address - Country:US
Mailing Address - Phone:253-732-9700
Mailing Address - Fax:
Practice Address - Street 1:4402 N 34TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98407-4728
Practice Address - Country:US
Practice Address - Phone:253-732-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023542174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist