Provider Demographics
NPI:1760229108
Name:KONZER, MARISA ANNE (NP-C)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:ANNE
Last Name:KONZER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:ANNE
Other - Last Name:POLSINELLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2207 MACE AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-2311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:45300 CHERRY HILL RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-5073
Practice Address - Country:US
Practice Address - Phone:734-981-3968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-12
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704342989363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily