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General NPI Number Information
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NPI Number | 1790460632
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Entity Type | Individual
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Provider Name | MARISSA LYNCH
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Gender | Female
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Dates
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Enumeration Date | 06/19/2023
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Last Update Date | 09/05/2023
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Provider Practice Location Address
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Address Line | 770 LINCOLN AVE STE 5
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City | FENNIMORE
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State | WI
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Zip | 53809-1563
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Country | US
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Telephone | 608-485-1352
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Fax |
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Provider Business Mailing Address
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Address Line | 2593 COUNTY ROAD M APT SUITE
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City | BOSCOBEL
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State | WI
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Zip | 53805-9517
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Country | US
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Telephone | 608-485-1352
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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 | 14351
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License Number State | WI
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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 | A174764
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License Number State | IA
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