Provider Demographics
NPI:1154156321
Name:GLAZE, MARISSA (DNP, CRNA)
Entity type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:
Last Name:GLAZE
Suffix:
Gender:F
Credentials:DNP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:654 SALMON AVE
Mailing Address - Street 2:
Mailing Address - City:DEPTFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-3656
Mailing Address - Country:US
Mailing Address - Phone:609-617-7848
Mailing Address - Fax:
Practice Address - Street 1:65 W JIMMIE LEEDS RD
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:NJ
Practice Address - Zip Code:08240-9102
Practice Address - Country:US
Practice Address - Phone:609-652-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ151775367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered