Provider Demographics
NPI:1700407319
Name:MARTIN, MARISSA A (ATS)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:F
Credentials:ATS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7769 WINDOVER WAY
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-3717
Mailing Address - Country:US
Mailing Address - Phone:321-427-7302
Mailing Address - Fax:
Practice Address - Street 1:7769 WINDOVER WAY
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-3717
Practice Address - Country:US
Practice Address - Phone:321-427-7302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer