Healthcare Provider Details

I. General information

NPI: 1518803766
Provider Name (Legal Business Name): MARISSA LEE COPPERSMITH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 GREENBRIER RD
GREEN BAY WI
54311-6519
US

IV. Provider business mailing address

207 TOWER AVE
WHITELAW WI
54247-9624
US

V. Phone/Fax

Practice location:
  • Phone: 920-288-8000
  • Fax:
Mailing address:
  • Phone: 920-901-7462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number245979-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: