Healthcare Provider Details

I. General information

NPI: 1285489005
Provider Name (Legal Business Name): MARISSA FEDELE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2024
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 PURCELL ST
BRIGHTON CO
80601-3551
US

IV. Provider business mailing address

2901 PURCELL ST
BRIGHTON CO
80601-3550
US

V. Phone/Fax

Practice location:
  • Phone: 303-659-9700
  • Fax: 720-336-3989
Mailing address:
  • Phone: 303-659-9700
  • Fax: 720-336-3989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0008826
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: