Healthcare Provider Details

I. General information

NPI: 1902324205
Provider Name (Legal Business Name): MARISSA BRENNAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARISSA TENNANT

II. Dates (important events)

Enumeration Date: 09/07/2017
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 MONTAUK AVE
NEW LONDON CT
06320-4700
US

IV. Provider business mailing address

365 MONTAUK AVE
NEW LONDON CT
06320-4700
US

V. Phone/Fax

Practice location:
  • Phone: 860-271-4364
  • Fax: 860-444-5114
Mailing address:
  • Phone: 860-271-4364
  • Fax: 860-444-5114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3987
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA01528
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: