Provider Demographics
NPI:1376623645
Name:O'TOOLE, MARYANNE (NP)
Entity Type:Individual
Prefix:
First Name:MARYANNE
Middle Name:
Last Name:O'TOOLE
Suffix:
Gender:F
Credentials:NP
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 1413
Mailing Address - Street 2:
Mailing Address - City:WELLFLEET
Mailing Address - State:MA
Mailing Address - Zip Code:02667
Mailing Address - Country:US
Mailing Address - Phone:508-240-0208
Mailing Address - Fax:508-240-0499
Practice Address - Street 1:49 HARRY KEMP WAY
Practice Address - Street 2:
Practice Address - City:PROVINCETOWN
Practice Address - State:MA
Practice Address - Zip Code:02657
Practice Address - Country:US
Practice Address - Phone:508-487-9395
Practice Address - Fax:508-487-3285
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA190922363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0710822Medicaid
MANP0166OtherCONNECTICARE
MANP0166OtherBLUE CROSS
MANP0166Medicare PIN
MANP0166OtherBLUE CROSS