Provider Demographics
NPI:1780653311
Name:KELLY, MARILYN (NP)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:KELLY
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 1:70 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:FOXBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02035-5312
Mailing Address - Country:US
Mailing Address - Phone:617-562-5482
Mailing Address - Fax:
Practice Address - Street 1:70 WALNUT ST
Practice Address - Street 2:
Practice Address - City:FOXBORO
Practice Address - State:MA
Practice Address - Zip Code:02035-5312
Practice Address - Country:US
Practice Address - Phone:617-562-5482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA98556363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP2436OtherBC/BS
MANP2436Medicare ID - Type Unspecified
MAPO6730Medicare UPIN