Healthcare Provider Details

I. General information

NPI: 1962054304
Provider Name (Legal Business Name): MARISSA ROSE SUHOCKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1180 E MAIN ST
COLUMBUS OH
43205-1902
US

IV. Provider business mailing address

2780 AIRPORT DR STE 100
COLUMBUS OH
43219-2289
US

V. Phone/Fax

Practice location:
  • Phone: 614-645-5535
  • Fax: 614-645-5517
Mailing address:
  • Phone: 614-859-1900
  • Fax: 614-645-5517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number025012
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: