Provider Demographics
NPI:1770378374
Name:LUMLEY, MARISSA GRACE
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:GRACE
Last Name:LUMLEY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:GRACE
Other - Last Name:VAN GLAHN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1400 OLD COUNTRY RD STE C103N
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-5156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 OLD COUNTRY RD STE C103N
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-5156
Practice Address - Country:US
Practice Address - Phone:631-786-7041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist