MEDICARE: MARISSA CHANTORN

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	95329832	CA

General Provider Information

NPI Number	:	1831883008
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISSA CHANTORN

Provider Business Mailing Address
First Line	:	2935 LORAIN RD
Second Line	:
City	:	SAN MARINO
State	:	CA
Zip	:	91108-2734
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1101 N SEPULVEDA BLVD STE 201
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-5963
Country	:	US
Telephone Number	:	877-859-2341
Fax Number	:

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

Provider Enumeration Date	:	06/08/2023
Last Update Date	:	06/08/2023

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Directions to “ MARISSA CHANTORN ” Practice Location

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