MEDICARE: MARYISSA EILEEN YOUNG

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	163W00000X	Registered Nurse	4704315186	MI
2	363LP0200X	Pediatric Nurse Practitioner	4704315186	MI

General Provider Information

NPI Number	:	1447015714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYISSA EILEEN YOUNG

Provider Business Mailing Address
First Line	:	3487 S LINDEN RD
Second Line	:
City	:	FLINT
State	:	MI
Zip	:	48507-3025
Country	:	US
Telephone Number	:	866-498-3909
Fax Number	:

Provider Business Practice Location Address
First Line	:	1205 S MISSION ST STE 4
Second Line	:
City	:	MT PLEASANT
State	:	MI
Zip	:	48858-3939
Country	:	US
Telephone Number	:	989-400-4369
Fax Number	:

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

Provider Enumeration Date	:	02/15/2024
Last Update Date	:	09/24/2024

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Directions to “ MARYISSA EILEEN YOUNG ” Practice Location

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