=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679069850
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARISSA LEE ROSE FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2018
-----------------------------------------------------
Last Update Date | 07/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1982 W MAIN ST STE 101
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85201-6917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-677-8282
-----------------------------------------------------
Fax | 844-470-2777
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 261 N ROOSEVELT AVE
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85226-2617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-677-8282
-----------------------------------------------------
Fax | 844-470-2777
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | AP11499
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------