Provider Demographics
NPI:1164226981
Name:RUST, MARISA NICHOLE (PMHNP)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:NICHOLE
Last Name:RUST
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 W SOUTHLAKE BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-7050
Mailing Address - Country:US
Mailing Address - Phone:972-200-8148
Mailing Address - Fax:682-477-3694
Practice Address - Street 1:271 W SOUTHLAKE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-7049
Practice Address - Country:US
Practice Address - Phone:972-200-8148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-02
Last Update Date:2025-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1205173363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health