Provider Demographics
NPI:1205482403
Name:WIESELER, MARISA CHRISTINE (APRN)
Entity type:Individual
Prefix:MRS
First Name:MARISA
Middle Name:CHRISTINE
Last Name:WIESELER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:MARISA
Other - Middle Name:CHRISTINE
Other - Last Name:VALDES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:4190 BELFORT RD
Mailing Address - Street 2:#140
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216
Mailing Address - Country:US
Mailing Address - Phone:904-296-2999
Mailing Address - Fax:904-490-8394
Practice Address - Street 1:4190 BELFORT RD STE 140
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-5871
Practice Address - Country:US
Practice Address - Phone:904-296-2999
Practice Address - Fax:904-490-8394
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10150363LF0000X
FL11003263363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health