Provider Demographics
NPI:1356108880
Name:ALLEN, MARISSA ANN (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:ANN
Last Name:ALLEN
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:ANN
Other - Last Name:FANTASIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2111 MISSION AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92058-2395
Mailing Address - Country:US
Mailing Address - Phone:619-559-4406
Mailing Address - Fax:
Practice Address - Street 1:2111 MISSION AVE
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058-2395
Practice Address - Country:US
Practice Address - Phone:619-559-4406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-01
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA809898163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool