Basic Information
| Provider Information | |||||||||
| NPI: | 1386396398 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUETTMAN | ||||||||
| FirstName: | MARISSA | ||||||||
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| Credential: | WHNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2908 WOODLAND CT | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528032142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5639403385 | ||||||||
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| Practice Location | |||||||||
| Address1: | 865 LINCOLN RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | BETTENDORF | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527224159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633551000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2022 | ||||||||
| LastUpdateDate: | 01/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | F166983 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 104416834 | 01 | NATIONAL CERTIFICATION CORPORATION | OTHER |