Provider Demographics
NPI:1588450217
Name:FREKING, MARISSA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:FREKING
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 KATIE CT
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-2313
Mailing Address - Country:US
Mailing Address - Phone:631-741-8631
Mailing Address - Fax:
Practice Address - Street 1:200 BELLE TERRE RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1968
Practice Address - Country:US
Practice Address - Phone:631-741-8631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-18
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY931408163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice