Provider Demographics
NPI:1982657789
Name:REILLY, MAUREEN (NP)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:REILLY
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 1:747 AQUIDNECK AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02842-7265
Mailing Address - Country:US
Mailing Address - Phone:401-619-4106
Mailing Address - Fax:401-293-0936
Practice Address - Street 1:747 AQUIDNECK AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-7265
Practice Address - Country:US
Practice Address - Phone:401-619-4106
Practice Address - Fax:401-293-0936
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RINPP37165363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIMR49501Medicaid