Provider Demographics
NPI:1063757979
Name:BENNETT, MARISSA RENEE (PA-C)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:RENEE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:RENEE
Other - Last Name:DEFONDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2652 DARLINGTON RD STE 10
Mailing Address - Street 2:
Mailing Address - City:BEAVER FALLS
Mailing Address - State:PA
Mailing Address - Zip Code:15010-1295
Mailing Address - Country:US
Mailing Address - Phone:724-891-3278
Mailing Address - Fax:
Practice Address - Street 1:2652 DARLINGTON RD STE 10
Practice Address - Street 2:
Practice Address - City:BEAVER FALLS
Practice Address - State:PA
Practice Address - Zip Code:15010-1295
Practice Address - Country:US
Practice Address - Phone:724-891-3278
Practice Address - Fax:724-847-2785
Is Sole Proprietor?:No
Enumeration Date:2012-12-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA002924363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical