Healthcare Provider Details

I. General information

NPI: 1073708145
Provider Name (Legal Business Name): CARRIE VIRGINIA MARSHALL PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 09/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 ROUTE 130
FORESTDALE MA
02644-1402
US

IV. Provider business mailing address

21 BEACON ST APT. 7A
BOSTON MA
02108-2804
US

V. Phone/Fax

Practice location:
  • Phone: 508-477-5306
  • Fax:
Mailing address:
  • Phone: 857-991-1299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number237573
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: