Provider Demographics
NPI:1134895089
Name:CANNATA, MARISSA NICOLE (FNP)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:NICOLE
Last Name:CANNATA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 KIM PL
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-5025
Mailing Address - Country:US
Mailing Address - Phone:631-707-6322
Mailing Address - Fax:
Practice Address - Street 1:450 LAKEVILLE RD
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1118
Practice Address - Country:US
Practice Address - Phone:516-734-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-20
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY348212363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily