Provider Demographics
NPI:1104981885
Name:STELLY-GENDRON, MARILYN M (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:M
Last Name:STELLY-GENDRON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-6245
Mailing Address - Country:US
Mailing Address - Phone:978-459-0389
Mailing Address - Fax:978-459-7642
Practice Address - Street 1:35 MARKET ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-6245
Practice Address - Country:US
Practice Address - Phone:978-459-0389
Practice Address - Fax:978-459-7642
Is Sole Proprietor?:No
Enumeration Date:2006-12-24
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA205899363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP2918Medicare ID - Type UnspecifiedMEDICARE B PROVIDER