MEDICARE: MS. MARLENE DISSETTE FNP, WHCNP

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	363LW0102X	Women's Health Nurse Practitioner	200650009NP	OR
2	261QP2300X	Primary Care Clinic/Center	200850011NP	OR

General Provider Information

NPI Number	:	1093820698
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARLENE DISSETTE FNP, WHCNP

Provider Business Mailing Address
First Line	:	3015 NE WEST DEVILS LAKE RD
Second Line	:
City	:	LINCOLN CITY
State	:	OR
Zip	:	97367-5131
Country	:	US
Telephone Number	:	541-994-8911
Fax Number	:

Provider Business Practice Location Address
First Line	:	3015 NE WEST DEVILS LAKE RD
Second Line	:
City	:	LINCOLN CITY
State	:	OR
Zip	:	97367-5131
Country	:	US
Telephone Number	:	541-994-8911
Fax Number	:

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

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	10/08/2014

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