Healthcare Provider Details

I. General information

NPI: 1992641799
Provider Name (Legal Business Name): JESSIE LAURORE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2026
Last Update Date: 04/25/2026
Certification Date: 04/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W CAMPUS DR
ORANGE CT
06477-3646
US

IV. Provider business mailing address

5 EDWIN ST APT 2
BOSTON MA
02124-2525
US

V. Phone/Fax

Practice location:
  • Phone: 774-826-6019
  • Fax:
Mailing address:
  • Phone: 774-826-6019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN10016081
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: