Provider Demographics
NPI:1730503855
Name:POOLE, MARISSA LYNN (FNP)
Entity type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:LYNN
Last Name:POOLE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:MARISSA
Other - Middle Name:L
Other - Last Name:WIESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:BANNER UNIVERSITY OF ARIZONA CANCER CENTER
Mailing Address - Street 2:3838 N CAMPBELL AVE BLDG 1
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719
Mailing Address - Country:US
Mailing Address - Phone:520-694-2873
Mailing Address - Fax:520-694-0338
Practice Address - Street 1:BANNER UNIVERSITY OF ARIZONA CANCER CENTER
Practice Address - Street 2:3838 N CAMPBELL AVE BLDG 1
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719
Practice Address - Country:US
Practice Address - Phone:520-694-2873
Practice Address - Fax:520-694-0338
Is Sole Proprietor?:No
Enumeration Date:2014-02-10
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP5278363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZPENDINGMedicare PIN