Provider Demographics
NPI:1174889216
Name:CANCELLIERE, MARIAN (APRN)
Entity type:Individual
Prefix:
First Name:MARIAN
Middle Name:
Last Name:CANCELLIERE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MARIAN
Other - Middle Name:
Other - Last Name:DIACHENKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:587 MIDDLE TPKE E
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-3731
Mailing Address - Country:US
Mailing Address - Phone:860-874-4774
Mailing Address - Fax:860-645-4132
Practice Address - Street 1:587 MIDDLE TPKE E
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-3731
Practice Address - Country:US
Practice Address - Phone:860-874-4774
Practice Address - Fax:860-645-4132
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001653364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health