Healthcare Provider Details

I. General information

NPI: 1790617280
Provider Name (Legal Business Name): MS. LISA MARIE TATTERSALL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 CHARTIER DR
BELCHERTOWN MA
01007-9760
US

IV. Provider business mailing address

19 CHARTIER DR
BELCHERTOWN MA
01007-9760
US

V. Phone/Fax

Practice location:
  • Phone: 774-365-1812
  • Fax:
Mailing address:
  • Phone: 774-365-1812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRN10000851
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: