Healthcare Provider Details

I. General information

NPI: 1215715784
Provider Name (Legal Business Name): MARISSA MICHELLE MOORE PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5060 BRADENTON AVE STE A
DUBLIN OH
43017-3511
US

IV. Provider business mailing address

5060 BRADENTON AVE STE A
DUBLIN OH
43017-3511
US

V. Phone/Fax

Practice location:
  • Phone: 216-407-1647
  • Fax:
Mailing address:
  • Phone: 216-407-1647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.0037466
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number473399
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: