Provider Demographics
NPI:1659744191
Name:MARSHALL, VANESSA LARA
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:LARA
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 ROYALSTON RD
Mailing Address - Street 2:
Mailing Address - City:PHILLIPSTON
Mailing Address - State:MA
Mailing Address - Zip Code:01331-9415
Mailing Address - Country:US
Mailing Address - Phone:774-245-3701
Mailing Address - Fax:978-428-0080
Practice Address - Street 1:501 ROYALSTON RD
Practice Address - Street 2:
Practice Address - City:PHILLIPSTON
Practice Address - State:MA
Practice Address - Zip Code:01331-9415
Practice Address - Country:US
Practice Address - Phone:774-245-3701
Practice Address - Fax:978-428-0080
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-05
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2263278363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner