Provider Demographics
NPI:1952662033
Name:DWARICA, MARISSA F (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:F
Last Name:DWARICA
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2152 RALPH AVE
Mailing Address - Street 2:346
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-5406
Mailing Address - Country:US
Mailing Address - Phone:718-781-7654
Mailing Address - Fax:
Practice Address - Street 1:42-09 28TH ST
Practice Address - Street 2:25N 11TH FL
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101
Practice Address - Country:US
Practice Address - Phone:347-396-4794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-05
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY528714163WS0200X
NY402580363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163WS0200XNursing Service ProvidersRegistered NurseSchoolGroup - Single Specialty