Provider Demographics
NPI:1255633194
Name:GOVE, MARITA AGNES (NP)
Entity type:Individual
Prefix:MRS
First Name:MARITA
Middle Name:AGNES
Last Name:GOVE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:MARITA
Other - Middle Name:
Other - Last Name:AGNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 526
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01903-0626
Mailing Address - Country:US
Mailing Address - Phone:781-598-8128
Mailing Address - Fax:781-596-3733
Practice Address - Street 1:269 UNION ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1314
Practice Address - Country:US
Practice Address - Phone:781-598-8128
Practice Address - Fax:781-596-3733
Is Sole Proprietor?:No
Enumeration Date:2010-11-29
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1021608363LF0000X
MARN2258892363LF0000X
NH067149-21363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3087047Medicaid