Healthcare Provider Details

I. General information

NPI: 1639720972
Provider Name (Legal Business Name): MARISSA BOTTOS FNP, APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARISSA SMITH

II. Dates (important events)

Enumeration Date: 09/27/2019
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9410 CALUMET AVE STE 401
MUNSTER IN
46321-0018
US

IV. Provider business mailing address

9410 CALUMET AVE STE 401
MUNSTER IN
46321-0018
US

V. Phone/Fax

Practice location:
  • Phone: 219-922-4900
  • Fax: 219-836-9922
Mailing address:
  • Phone: 219-922-4900
  • Fax: 219-836-9922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71009430A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: