Provider Demographics
NPI:1083081046
Name:MONTAQUE, MARIYAN (DNP, FNP-BC)
Entity type:Individual
Prefix:
First Name:MARIYAN
Middle Name:
Last Name:MONTAQUE
Suffix:
Gender:
Credentials:DNP, 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:PO BOX 142
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:MA
Mailing Address - Zip Code:01564-0142
Mailing Address - Country:US
Mailing Address - Phone:978-870-4397
Mailing Address - Fax:
Practice Address - Street 1:242 GREEN ST
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440-1373
Practice Address - Country:US
Practice Address - Phone:978-630-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-25
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH070619-21163W00000X
MI4704289575163W00000X
MARN2274743207Q00000X, 363L00000X
MA2274743363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily