Provider Demographics
NPI:1124438734
Name:DRAKE, MARISSA (CNP)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:DRAKE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 FORD PKWY
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-1931
Mailing Address - Country:US
Mailing Address - Phone:612-256-8225
Mailing Address - Fax:612-457-0216
Practice Address - Street 1:2004 FORD PKWY
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-1931
Practice Address - Country:US
Practice Address - Phone:612-256-8225
Practice Address - Fax:612-457-0216
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 185046-6163WM0705X, 363LF0000X
MN2407363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical