Provider Demographics
NPI:1659744191
Name:MARSHALL, VANESSA LARA
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:LARA
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 ROYALSTON RD
Mailing Address - Street 2:
Mailing Address - City:PHILLIPSTON
Mailing Address - State:MA
Mailing Address - Zip Code:01331-9415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:428 SHREWSBURY ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-1661
Practice Address - Country:US
Practice Address - Phone:508-754-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2263278363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner