Healthcare Provider Details

I. General information

NPI: 1861790479
Provider Name (Legal Business Name): LAURA SUSANNAH TANNENBAUM NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2011
Last Update Date: 07/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 DOW AVE
ARLINGTON MA
02476-7142
US

IV. Provider business mailing address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

V. Phone/Fax

Practice location:
  • Phone: 781-643-0804
  • Fax:
Mailing address:
  • Phone: 617-355-8076
  • Fax: 617-730-0902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number236051
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: