Provider Demographics
NPI:1134925332
Name:PENICHE, MARISSA JEAN (RN, FNP STUDENT)
Entity type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:JEAN
Last Name:PENICHE
Suffix:
Gender:
Credentials:RN, FNP STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 PICKETT ST APT E
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24073-1331
Mailing Address - Country:US
Mailing Address - Phone:540-505-7245
Mailing Address - Fax:
Practice Address - Street 1:600 RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:RADFORD
Practice Address - State:VA
Practice Address - Zip Code:24141-2428
Practice Address - Country:US
Practice Address - Phone:540-639-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001296088163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care