Provider Demographics
NPI:1508609587
Name:JOHNSON, MARISSA (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:
Credentials:FNP-C
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:
Other - Last Name:CAMPANELLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:112 MEDICAL VILLAGE DR STE G
Mailing Address - Street 2:
Mailing Address - City:WALLACE
Mailing Address - State:NC
Mailing Address - Zip Code:28466-1665
Mailing Address - Country:US
Mailing Address - Phone:910-552-1580
Mailing Address - Fax:910-665-1780
Practice Address - Street 1:510 CAROLINA BAY DR STE 110
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-2046
Practice Address - Country:US
Practice Address - Phone:910-662-6000
Practice Address - Fax:910-550-3787
Is Sole Proprietor?:No
Enumeration Date:2024-06-17
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC326265363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner