MEDICARE: MARISSA RAE SIMON NP

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	363L00000X	Nurse Practitioner	NP500018563	DC
2	363L00000X	Nurse Practitioner	LP-0010943	DE
3	363L00000X	Nurse Practitioner	F310799-01	NY
4	363L00000X	Nurse Practitioner	1142299	TX
5	363L00000X	Nurse Practitioner	26NJ15066200	NJ
6	363L00000X	Nurse Practitioner	R266020	MD

General Provider Information

NPI Number	:	1114643822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISSA RAE SIMON NP

Provider Business Mailing Address
First Line	:	9110 E NICHOLS AVE STE 150
Second Line	:
City	:	CENTENNIAL
State	:	CO
Zip	:	80112-3450
Country	:	US
Telephone Number	:	720-666-4739
Fax Number	:

Provider Business Practice Location Address
First Line	:	633 3RD AVE RM 9B
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10017-0091
Country	:	US
Telephone Number	:	720-666-4739
Fax Number	:

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

Provider Enumeration Date	:	10/13/2022
Last Update Date	:	10/24/2025

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