=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629704929
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARISSA ANNE ONTIS FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2022
-----------------------------------------------------
Last Update Date | 11/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 MAPLE SUMMIT RD STE 200
-----------------------------------------------------
City | JERSEYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62052-2028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-498-4325
-----------------------------------------------------
Fax | 618-498-9898
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 390 MAPLE SUMMIT RD
-----------------------------------------------------
City | JERSEYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62052-2000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-498-7518
-----------------------------------------------------
Fax | 618-498-3052
-----------------------------------------------------
=====================================================
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 | 209025582
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------