Provider Demographics
NPI:1811322373
Name:UDELSMAN, MARISSA ANN (APRN)
Entity type:Individual
Prefix:MS
First Name:MARISSA
Middle Name:ANN
Last Name:UDELSMAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:ANN
Other - Last Name:BOARDMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:30 WARREN ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-3602
Mailing Address - Country:US
Mailing Address - Phone:617-254-3800
Mailing Address - Fax:
Practice Address - Street 1:30 WARREN ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-3602
Practice Address - Country:US
Practice Address - Phone:617-254-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-03
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2305855363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics