Healthcare Provider Details

I. General information

NPI: 1083202006
Provider Name (Legal Business Name): MARISSA HERTLING CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2021
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GUSTAVE L LEVY PL # 1208
NEW YORK NY
10029-6504
US

IV. Provider business mailing address

286 ARCH ST
OCEANSIDE NY
11572-4302
US

V. Phone/Fax

Practice location:
  • Phone: 212-241-7022
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number383212
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: