Basic Information
| Provider Information | |||||||||
| NPI: | 1538479480 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANUEL | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 61 WHITCHER STREET, | ||||||||
| Address2: | #3110 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704222326 | ||||||||
| FaxNumber: | 7704227797 | ||||||||
| Practice Location | |||||||||
| Address1: | 61 WHITCHER ST NE | ||||||||
| Address2: | #3110 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704222326 | ||||||||
| FaxNumber: | 7704227797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2010 | ||||||||
| LastUpdateDate: | 04/16/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | NP20026 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.