Provider Demographics
NPI:1023166634
Name:PREVIDE, MARISA (RN, PHN)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:PREVIDE
Suffix:
Gender:F
Credentials:RN, PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4214 FRONTERA DR
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-6711
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:137 N. COTTONWOOD
Practice Address - Street 2:SUITE 2450
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695
Practice Address - Country:US
Practice Address - Phone:530-666-8645
Practice Address - Fax:530-666-7447
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA641664163W00000X, 163WC0400X, 163WC1500X, 163WI0600X, 163WM0102X, 163WW0101X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WI0600XNursing Service ProvidersRegistered NurseInfection Control
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn
No163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory