Healthcare Provider Details

I. General information

NPI: 1942240197
Provider Name (Legal Business Name): DEBORAH A VAN ETTEN MS,APRN,BC,CS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 08/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 CONCORD AVE
BELMONT MA
02478-4046
US

IV. Provider business mailing address

1 LORING RD
LEXINGTON MA
02421-6907
US

V. Phone/Fax

Practice location:
  • Phone: 617-251-6896
  • Fax:
Mailing address:
  • Phone: 781-861-1752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number155485
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: