Provider Demographics
NPI:1063014884
Name:CAVETT, MARISSA DANIELLE
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:DANIELLE
Last Name:CAVETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT ST STE 520
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4430
Mailing Address - Country:US
Mailing Address - Phone:267-606-4478
Mailing Address - Fax:
Practice Address - Street 1:34 LAWLEY DR
Practice Address - Street 2:
Practice Address - City:LINCROFT
Practice Address - State:NJ
Practice Address - Zip Code:07738-1553
Practice Address - Country:US
Practice Address - Phone:908-812-2203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMA062293363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty