Healthcare Provider Details

I. General information

NPI: 1942128160
Provider Name (Legal Business Name): MARISA MARIA MONTELEONE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 W MAPLE RD STE 101
BLOOMFIELD TOWNSHIP MI
48301-3118
US

IV. Provider business mailing address

28004 ROY ST
SAINT CLAIR SHORES MI
48081-2945
US

V. Phone/Fax

Practice location:
  • Phone: 248-885-8211
  • Fax:
Mailing address:
  • Phone: 586-850-1445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704363273
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: