Healthcare Provider Details

I. General information

NPI: 1629704929
Provider Name (Legal Business Name): MARISSA ANNE ONTIS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARISSA ANNE DELP

II. Dates (important events)

Enumeration Date: 07/28/2022
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEMORIAL DR # G181
ALTON IL
62002-6755
US

IV. Provider business mailing address

1 MEMORIAL DR # G-181
ALTON IL
62002-6722
US

V. Phone/Fax

Practice location:
  • Phone: 618-433-7066
  • Fax: 618-433-7060
Mailing address:
  • Phone: 618-433-4066
  • Fax: 618-433-7060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209025582
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: