Healthcare Provider Details

I. General information

NPI: 1972252047
Provider Name (Legal Business Name): MARISA ANN ZITO M.S., PA-C, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2022
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22726 MYLLS ST
SAINT CLAIR SHORES MI
48081-2622
US

IV. Provider business mailing address

22726 MYLLS ST
SAINT CLAIR SHORES MI
48081-2622
US

V. Phone/Fax

Practice location:
  • Phone: 586-944-8505
  • Fax:
Mailing address:
  • Phone: 586-944-8505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601010921
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: