MEDICARE: MADISON RAE DEWOLFE RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN2316982	MA
2	363L00000X	Nurse Practitioner	RN2316982	MA

General Provider Information

NPI Number	:	1376287227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADISON RAE DEWOLFE RN

Provider Business Mailing Address
First Line	:	67 MILLBROOK ST STE 406A
Second Line	:
City	:	WORCESTER
State	:	MA
Zip	:	01606-2845
Country	:	US
Telephone Number	:	508-283-4513
Fax Number	:	508-469-4057

Provider Business Practice Location Address
First Line	:	67 MILLBROOK ST
Second Line	:
City	:	WORCESTER
State	:	MA
Zip	:	01606-2835
Country	:	US
Telephone Number	:	508-283-4513
Fax Number	:	508-469-4057

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2022
Last Update Date	:	11/02/2022

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