Healthcare Provider Details

I. General information

NPI: 1982428066
Provider Name (Legal Business Name): HEROLD JEROME RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2024
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 MCCOY ST
AVON MA
02322-1608
US

IV. Provider business mailing address

65 MCCOY ST
AVON MA
02322-1608
US

V. Phone/Fax

Practice location:
  • Phone: 781-510-2069
  • Fax:
Mailing address:
  • Phone: 781-510-2069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN2348469
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: