Provider Demographics
NPI:1376024943
Name:ECKSTROM, MARIAH (RN)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:ECKSTROM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 WYCHUNAS AVE
Mailing Address - Street 2:
Mailing Address - City:BUZZARDS BAY
Mailing Address - State:MA
Mailing Address - Zip Code:02532-4318
Mailing Address - Country:US
Mailing Address - Phone:774-238-9122
Mailing Address - Fax:
Practice Address - Street 1:64 WYCHUNAS AVE
Practice Address - Street 2:
Practice Address - City:BUZZARDS BAY
Practice Address - State:MA
Practice Address - Zip Code:02532-4318
Practice Address - Country:US
Practice Address - Phone:774-238-9122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2327109163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse