Healthcare Provider Details

I. General information

NPI: 1962132043
Provider Name (Legal Business Name): MARISSA LUNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 S NATIONAL AVE # PROF160
SPRINGFIELD MO
65897-0001
US

IV. Provider business mailing address

517 S E ST
LE ROY KS
66857-9560
US

V. Phone/Fax

Practice location:
  • Phone: 417-836-8924
  • Fax:
Mailing address:
  • Phone: 620-364-6533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: