Provider Demographics
NPI:1629801105
Name:TADDIE, MARISSA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:TADDIE
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 1:39 DOLLAR RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-1401
Mailing Address - Country:US
Mailing Address - Phone:304-216-1994
Mailing Address - Fax:
Practice Address - Street 1:39 DOLLAR RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501-1401
Practice Address - Country:US
Practice Address - Phone:304-216-1994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-21
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist