Provider Demographics
NPI:1881264356
Name:COMMODORE, MARISSA LYNETTE (CRNA)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:LYNETTE
Last Name:COMMODORE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5357 WINDFERN CT
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30088-3329
Mailing Address - Country:US
Mailing Address - Phone:770-875-3080
Mailing Address - Fax:
Practice Address - Street 1:5357 WINDFERN CT
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30088-3329
Practice Address - Country:US
Practice Address - Phone:770-875-3080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN264280207L00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology