Provider Demographics
NPI:1669117370
Name:LOPEZ, MARISSA ANN (NP)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:ANN
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:240 N TILLOTSON AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-3988
Mailing Address - Country:US
Mailing Address - Phone:765-288-1928
Mailing Address - Fax:765-741-0335
Practice Address - Street 1:500 W VOTAW ST STE A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:IN
Practice Address - Zip Code:47371-1322
Practice Address - Country:US
Practice Address - Phone:260-726-4350
Practice Address - Fax:260-726-9340
Is Sole Proprietor?:No
Enumeration Date:2022-04-28
Last Update Date:2022-06-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN28212155A163W00000X
IN71012622A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse