Provider Demographics
NPI:1922161801
Name:DONAHUE, MARINA (NP)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:DONAHUE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARINA
Other - Middle Name:
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:221 LONGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5804
Mailing Address - Country:US
Mailing Address - Phone:617-732-5556
Mailing Address - Fax:617-525-0436
Practice Address - Street 1:221 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5804
Practice Address - Country:US
Practice Address - Phone:617-732-5556
Practice Address - Fax:617-525-0436
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN191587363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110074585AMedicaid
MA110074585AMedicaid