Provider Demographics
NPI:1386115350
Name:WALSH, MARISSA LYNN (PA)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:LYNN
Last Name:WALSH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-469-2000
Mailing Address - Fax:
Practice Address - Street 1:430 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-4464
Practice Address - Country:US
Practice Address - Phone:630-545-7855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL085006976363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program