Basic Information
| Provider Information | |||||||||
| NPI: | 1538789003 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARELIS | ||||||||
| FirstName: | WANDA | ||||||||
| MiddleName: | |||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 ESSEX ST | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018414396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786892400 | ||||||||
| FaxNumber: | 9786830663 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 ESSEX ST | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018414396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786892400 | ||||||||
| FaxNumber: | 9786830663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2020 | ||||||||
| LastUpdateDate: | 02/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN2310678 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.