Provider Demographics
NPI:1689183808
Name:PETRILLI, MARIELLE (RN, FNP)
Entity Type:Individual
Prefix:
First Name:MARIELLE
Middle Name:
Last Name:PETRILLI
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 FRUIT STREET
Mailing Address - Street 2:YAWKEY 4B
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT STREET
Practice Address - Street 2:YAWKEY 4B
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-724-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-20
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2306198363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner