Provider Demographics
NPI:1881060861
Name:MARCELLIN, GREGORY (FNP-BC)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:MARCELLIN
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 DYER AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-1201
Mailing Address - Country:US
Mailing Address - Phone:857-869-0318
Mailing Address - Fax:
Practice Address - Street 1:1601 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-1951
Practice Address - Country:US
Practice Address - Phone:617-425-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-13
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6225363LF0000X
MARN2290802363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily