Healthcare Provider Details

I. General information

NPI: 1952911349
Provider Name (Legal Business Name): MARISSA LEE FIDLER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2020
Last Update Date: 08/08/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 W HIGHLANDS DR STE 240
ELLIJAY GA
30540-7745
US

IV. Provider business mailing address

370 W HIGHLANDS DR STE 240
EAST ELLIJAY GA
30540-7745
US

V. Phone/Fax

Practice location:
  • Phone: 706-635-1400
  • Fax:
Mailing address:
  • Phone: 706-635-1400
  • Fax: 706-635-1411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13127
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: