Provider Demographics
NPI:1902627193
Name:WHITE, MARISA C
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:C
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 MUNCEY RD
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-1813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6603 BEACH CHANNEL DR
Practice Address - Street 2:
Practice Address - City:ARVERNE
Practice Address - State:NY
Practice Address - Zip Code:11692-1433
Practice Address - Country:US
Practice Address - Phone:718-471-8671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY337383164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse