MEDICARE: MARISSA LYNN PETERSON RN, CNM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367A00000X	Advanced Practice Midwife	RN300285	GA
2	163W00000X	Registered Nurse	RN300285	GA

General Provider Information

NPI Number	:	1649821307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISSA LYNN PETERSON RN, CNM

Provider Business Mailing Address
First Line	:	242 S COASTAL HWY
Second Line	:
City	:	MIDWAY
State	:	GA
Zip	:	31320-5231
Country	:	US
Telephone Number	:	912-575-6100
Fax Number	:	866-583-4671

Provider Business Practice Location Address
First Line	:	242 S COASTAL HWY
Second Line	:
City	:	MIDWAY
State	:	GA
Zip	:	31320-5231
Country	:	US
Telephone Number	:	912-272-0778
Fax Number	:	866-583-4671

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/24/2019
Last Update Date	:	11/16/2025

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