Provider Demographics
NPI:1730856147
Name:VANVLEET, MARISHA LEE (APRN-CNP, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MARISHA
Middle Name:LEE
Last Name:VANVLEET
Suffix:
Gender:F
Credentials:APRN-CNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 FRONT ST STE 404
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-3589
Mailing Address - Country:US
Mailing Address - Phone:307-228-2328
Mailing Address - Fax:307-448-4606
Practice Address - Street 1:724 FRONT ST STE 404
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-3589
Practice Address - Country:US
Practice Address - Phone:307-288-2328
Practice Address - Fax:307-448-4606
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-24
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY32026364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE114001Other2ND APRN LICENS