Provider Demographics
NPI:1174108195
Name:DIXON, MARISSA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:DIXON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 KRYS VIEW DR
Mailing Address - Street 2:
Mailing Address - City:BRUCETON MILLS
Mailing Address - State:WV
Mailing Address - Zip Code:26525-9771
Mailing Address - Country:US
Mailing Address - Phone:724-970-7469
Mailing Address - Fax:
Practice Address - Street 1:47 KRYS VIEW DR
Practice Address - Street 2:
Practice Address - City:BRUCETON MILLS
Practice Address - State:WV
Practice Address - Zip Code:26525-9771
Practice Address - Country:US
Practice Address - Phone:724-970-7469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker