Provider Demographics
NPI:1457131336
Name:DIMAMBRO, MARISSA ROSE (DNP, PMHNP-BC)
Entity type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:ROSE
Last Name:DIMAMBRO
Suffix:
Gender:F
Credentials:DNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2904 WOLCOTT ST
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-1035
Mailing Address - Country:US
Mailing Address - Phone:248-805-4821
Mailing Address - Fax:
Practice Address - Street 1:1300 BROADWAY ST STE 400
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-2202
Practice Address - Country:US
Practice Address - Phone:248-805-4821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704329820363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health