Provider Demographics
NPI:1255430666
Name:PATTERSON, MARISSA KYNE
Entity type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:KYNE
Last Name:PATTERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10655 YUNKER DR
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33774-4529
Mailing Address - Country:US
Mailing Address - Phone:727-535-6746
Mailing Address - Fax:727-536-6006
Practice Address - Street 1:14141 46TH ST N
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33762-3868
Practice Address - Country:US
Practice Address - Phone:727-535-6746
Practice Address - Fax:727-536-6006
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT10587225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL888489700Medicaid