MEDICARE: MARISSA ELIZABETH FETHERMAN D.C.

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	111N00000X	Chiropractor	CH11265	FL

General Provider Information

NPI Number	:	1245533025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISSA ELIZABETH FETHERMAN D.C.

Provider Business Mailing Address
First Line	:	6152 N US HIGHWAY 41
Second Line	:
City	:	APOLLO BEACH
State	:	FL
Zip	:	33572-1806
Country	:	US
Telephone Number	:	586-255-0393
Fax Number	:

Provider Business Practice Location Address
First Line	:	6152 N US HIGHWAY 41
Second Line	:
City	:	APOLLO BEACH
State	:	FL
Zip	:	33572-1806
Country	:	US
Telephone Number	:	586-255-0393
Fax Number	:

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

Provider Enumeration Date	:	12/16/2010
Last Update Date	:	11/21/2015

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