Provider Demographics
NPI:1104461151
Name:STEVENS, MARISA CROMMETT
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:CROMMETT
Last Name:STEVENS
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 1:784 HERCULES DR STE 110
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-8049
Mailing Address - Country:US
Mailing Address - Phone:802-210-5953
Mailing Address - Fax:802-660-9438
Practice Address - Street 1:443 CONGRESS ST FL 2
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-3531
Practice Address - Country:US
Practice Address - Phone:866-476-1321
Practice Address - Fax:802-660-9437
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH081681-23363LA2200X, 363LG0600X, 363LW0102X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3122699Medicaid