Provider Demographics
NPI:1821408303
Name:MARSHALL, DERESSA LEE (APRN, FNP-C)
Entity type:Individual
Prefix:
First Name:DERESSA
Middle Name:LEE
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2710 TROTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-4903
Mailing Address - Country:US
Mailing Address - Phone:931-797-3040
Mailing Address - Fax:615-503-8809
Practice Address - Street 1:2710 TROTWOOD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4903
Practice Address - Country:US
Practice Address - Phone:615-503-8809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-05
Last Update Date:2024-05-16
Deactivation Date:2016-02-16
Deactivation Code:
Reactivation Date:2016-04-27
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000018269363LF0000X
TN18269363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0898Medicaid
TNQ041062Medicaid