=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417546177
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARISA DIAMOND JURISIC MSN, FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2021
-----------------------------------------------------
Last Update Date | 11/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6300 USA HEALTH BLVD.
-----------------------------------------------------
City | MOBILE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36608-0020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-633-8880
-----------------------------------------------------
Fax | 251-633-2817
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 21595
-----------------------------------------------------
City | BELFAST
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04915-4112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-318-2678
-----------------------------------------------------
Fax | 251-405-9500
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 1-154589
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------