Provider Demographics
NPI:1215531264
Name:MAHAN, MARISSA PAIGE (DNP, FNP-BC)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:PAIGE
Last Name:MAHAN
Suffix:
Gender:F
Credentials:DNP, FNP-BC
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:PAIGE
Other - Last Name:HOLLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 E PLUMMER BLVD
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-8047
Mailing Address - Country:US
Mailing Address - Phone:217-483-3487
Mailing Address - Fax:217-483-8150
Practice Address - Street 1:101 E PLUMMER BLVD
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:IL
Practice Address - Zip Code:62629-8047
Practice Address - Country:US
Practice Address - Phone:217-483-3487
Practice Address - Fax:217-483-8150
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020014749363LF0000X
IL209021387363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041443199OtherRN LICENSE