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General NPI Number Information
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NPI Number | 1689266793
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Entity Type | Individual
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Provider Name | MARISSA ADELE RESTIVO
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Gender | Female
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Dates
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Enumeration Date | 02/09/2021
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Last Update Date | 01/26/2022
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Provider Practice Location Address
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Address Line | 1103 VILLAGE SQUARE DR STE 100
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City | PERRYSBURG
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State | OH
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Zip | 43551-1762
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Country | US
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Telephone | 567-368-3213
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Fax |
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Provider Business Mailing Address
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Address Line | 1103 VILLAGE SQUARE DR STE 100
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City | PERRYSBURG
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State | OH
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Zip | 43551-1762
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 4704322696
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | APRN.CNP.0030045
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License Number State | OH
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