Provider Demographics
NPI:1932628583
Name:FUNK, MARISSA JENNIE (RN)
Entity type:Individual
Prefix:MS
First Name:MARISSA
Middle Name:JENNIE
Last Name:FUNK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28872 NW KEENON ST
Mailing Address - Street 2:
Mailing Address - City:NORTH PLAINS
Mailing Address - State:OR
Mailing Address - Zip Code:97133-7184
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23528 SW MIDDLETON RD
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-8864
Practice Address - Country:US
Practice Address - Phone:201-755-7070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-14
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201509280RN163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health