Provider Demographics
NPI:1164671194
Name:CONNELLY, MARIANNE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MARIANNE
Middle Name:
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MARIANNE
Other - Middle Name:
Other - Last Name:CORLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:385 BROADWAY STE 4
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-3059
Mailing Address - Country:US
Mailing Address - Phone:781-485-1000
Mailing Address - Fax:781-286-5418
Practice Address - Street 1:385 BROADWAY STE 4
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-3059
Practice Address - Country:US
Practice Address - Phone:781-485-1000
Practice Address - Fax:781-286-5418
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA263434363LF0000X
MARN263434363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000906901Medicare PIN