Healthcare Provider Details

I. General information

NPI: 1609882380
Provider Name (Legal Business Name): LORAE D. PHELAN RN,MS,CS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 GREAT RD SUITE 205
BEDFORD MA
01730-2729
US

IV. Provider business mailing address

100 WOODLAND RD
MALDEN MA
02148-1135
US

V. Phone/Fax

Practice location:
  • Phone: 617-529-7772
  • Fax: 781-687-2018
Mailing address:
  • Phone: 781-388-2394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number163625
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: