Provider Demographics
NPI:1972348480
Name:LUDWIG, MARISSA NICOLE
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:NICOLE
Last Name:LUDWIG
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 1:10300 INDIAN CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-2484
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10300 INDIAN CREEK PKWY
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66210-2484
Practice Address - Country:US
Practice Address - Phone:417-872-2745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2024028757363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program