Healthcare Provider Details

I. General information

NPI: 1316206352
Provider Name (Legal Business Name): JANE WAGEMA-JOHNSON GNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2012
Last Update Date: 05/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CUMMINGS CTR SUITE 222C
BEVERLY MA
01915-6115
US

IV. Provider business mailing address

100 CUMMINGS CTR SUITE 222C
BEVERLY MA
01915-6115
US

V. Phone/Fax

Practice location:
  • Phone: 978-524-9510
  • Fax:
Mailing address:
  • Phone: 978-524-9510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number242191
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: