Provider Demographics
NPI:1699420232
Name:MARINO, MARISSA AUTUMN (CRNP)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:AUTUMN
Last Name:MARINO
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 HIGHWAY 315 BLVD
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-6943
Mailing Address - Country:US
Mailing Address - Phone:570-235-1470
Mailing Address - Fax:570-550-9256
Practice Address - Street 1:1102 HIGHWAY 315 BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-6943
Practice Address - Country:US
Practice Address - Phone:570-235-1470
Practice Address - Fax:570-550-9256
Is Sole Proprietor?:No
Enumeration Date:2022-02-12
Last Update Date:2022-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN638114163W00000X
PASP025286363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse