Provider Demographics
NPI:1083081046
Name:MONTAQUE, MARIYAN (DNP, FNP-BC)
Entity Type:Individual
Prefix:
First Name:MARIYAN
Middle Name:
Last Name:MONTAQUE
Suffix:
Gender:F
Credentials:DNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:151 WORCESTER RD
Practice Address - Street 2:
Practice Address - City:BARRE
Practice Address - State:MA
Practice Address - Zip Code:01005-9002
Practice Address - Country:US
Practice Address - Phone:978-355-6321
Practice Address - Fax:978-355-6329
Is Sole Proprietor?:No
Enumeration Date:2015-08-25
Last Update Date:2020-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH070619-21163W00000X
MI4704289575163W00000X
MA2274743363LF0000X
MARN2274743207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily