MEDICARE: NANCY E DEFOREST NP

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	363L00000X	Nurse Practitioner	107372	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467447482
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NANCY E DEFOREST NP

Provider Business Mailing Address
First Line	:	77 WARREN ST
Second Line	:	ROOM 339
City	:	BRIGHTON
State	:	MA
Zip	:	02135-3601
Country	:	US
Telephone Number	:	617-562-5359
Fax Number	:	617-562-5415

Provider Business Practice Location Address
First Line	:	24 COMMON STREET,
Second Line	:	SUITE 1
City	:	WRENTHAM
State	:	MA
Zip	:	02093
Country	:	US
Telephone Number	:	508-384-2223
Fax Number	:	508-384-0066

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

Provider Enumeration Date	:	09/15/2005
Last Update Date	:	12/01/2009

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