Provider Demographics
NPI:1376214700
Name:MARR, AMANDA (NP-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MARR
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 WARREN AVE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-5928
Mailing Address - Country:US
Mailing Address - Phone:310-525-4486
Mailing Address - Fax:
Practice Address - Street 1:21 MERCHANTS ROW
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02109-2005
Practice Address - Country:US
Practice Address - Phone:617-973-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2287504363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner