Provider Demographics
NPI:1952855942
Name:LAVIN, MARISSA (APRN)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:LAVIN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:C/O NORTHEAST MEDICAL GROUP, INC.
Mailing Address - Street 2:226 MILL HILL AVE., 3RD FLOOR
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610-2826
Mailing Address - Country:US
Mailing Address - Phone:203-384-3388
Mailing Address - Fax:
Practice Address - Street 1:95 ARMORY RD
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-1753
Practice Address - Country:US
Practice Address - Phone:203-384-3388
Practice Address - Fax:203-384-4034
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6635363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily