Provider Demographics
NPI:1750728226
Name:MARONG, JACQUELINE ELYSE (NP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ELYSE
Last Name:MARONG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:ELYSE
Other - Last Name:DAIGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:92 MONTVALE AVE STE 4200
Mailing Address - Street 2:
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-3655
Mailing Address - Country:US
Mailing Address - Phone:781-451-0072
Mailing Address - Fax:
Practice Address - Street 1:92 MONTVALE AVE STE 4200
Practice Address - Street 2:
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-3655
Practice Address - Country:US
Practice Address - Phone:781-451-0072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-23
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2284774163W00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse