Provider Demographics
NPI:1649821307
Name:PETERSON, MARISSA LYNN (RN, CNM)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:LYNN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 E WHATLEY ST
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-3230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:242 S COASTAL HWY
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:GA
Practice Address - Zip Code:31320-5231
Practice Address - Country:US
Practice Address - Phone:912-272-0778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-24
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN300285163W00000X
367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse