Provider Demographics
NPI:1194430173
Name:DEGUSSEME, MARIAH LYNN (FNP-C)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:LYNN
Last Name:DEGUSSEME
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3424 MEADE ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80211-3141
Mailing Address - Country:US
Mailing Address - Phone:760-650-5773
Mailing Address - Fax:
Practice Address - Street 1:9362 TEDDY LN STE 103&104
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-2870
Practice Address - Country:US
Practice Address - Phone:303-955-7545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0998274363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily