Provider Demographics
NPI:1922874668
Name:MARISCO, VICTORIA RACHELLE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:RACHELLE
Last Name:MARISCO
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 CROSS CREEK PKWY APT 722
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-4429
Mailing Address - Country:US
Mailing Address - Phone:601-337-6593
Mailing Address - Fax:
Practice Address - Street 1:411 OAK ST
Practice Address - Street 2:
Practice Address - City:RICHTON
Practice Address - State:MS
Practice Address - Zip Code:39476-7447
Practice Address - Country:US
Practice Address - Phone:601-408-0719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906374363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health