Provider Demographics
NPI:1699106328
Name:RICHARDSON, MARCIENNE TALLIS (RN)
Entity type:Individual
Prefix:MS
First Name:MARCIENNE
Middle Name:TALLIS
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:MILDRED
Other - Middle Name:VIVIAN
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:415 BOSTON TURNPIKE
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545
Mailing Address - Country:US
Mailing Address - Phone:508-581-8952
Mailing Address - Fax:
Practice Address - Street 1:415 BOSTON TURNPIKE
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:MA
Practice Address - Zip Code:01545
Practice Address - Country:US
Practice Address - Phone:508-581-8952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-05
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN148075163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse