MEDICARE: MRS. MARISSA BRIANNA ALLEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1013770395
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARISSA BRIANNA ALLEN

Provider Business Mailing Address
First Line	:	8189 LITTLE SYDNEYS WAY
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29406-8922
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8189 LITTLE SYDNEYS WAY
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29406-8922
Country	:	US
Telephone Number	:	502-492-9929
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2024
Last Update Date	:	01/31/2024

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