Provider Demographics
NPI:1902061013
Name:HALVORSON, MARISSA C (LPN)
Entity Type:Individual
Prefix:MS
First Name:MARISSA
Middle Name:C
Last Name:HALVORSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 HILARY ST
Mailing Address - Street 2:
Mailing Address - City:WEST SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11796-1003
Mailing Address - Country:US
Mailing Address - Phone:631-750-6691
Mailing Address - Fax:
Practice Address - Street 1:106 HILARY ST
Practice Address - Street 2:
Practice Address - City:WEST SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11796-1003
Practice Address - Country:US
Practice Address - Phone:631-750-6691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY279317-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse