Provider Demographics
NPI:1861427742
Name:LEWIS, MARYANNE (APRN,BC)
Entity type:Individual
Prefix:
First Name:MARYANNE
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:APRN,BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 GENNARO CIR
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01778-4436
Mailing Address - Country:US
Mailing Address - Phone:508-653-3870
Mailing Address - Fax:
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-5159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA119179363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics