Provider Demographics
NPI:1174578983
Name:PELLETIER, MARIANNE (CNM)
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
Last Name:PELLETIER
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 WALTON ST
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420
Mailing Address - Country:US
Mailing Address - Phone:508-868-3450
Mailing Address - Fax:978-345-2417
Practice Address - Street 1:350 WALTON ST
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-5342
Practice Address - Country:US
Practice Address - Phone:508-868-3450
Practice Address - Fax:978-345-2417
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA182806367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0343480Medicaid
MA0343480Medicaid
MA0343480Medicaid