Healthcare Provider Details

I. General information

NPI: 1780242156
Provider Name (Legal Business Name): MARTHA REARDON RN, WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2019
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 BROOKLINE AVE
BOSTON MA
02215-3904
US

IV. Provider business mailing address

133 BROOKLINE AVE
BOSTON MA
02215-3904
US

V. Phone/Fax

Practice location:
  • Phone: 617-421-1000
  • Fax:
Mailing address:
  • Phone: 617-421-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2316889
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberRN2316889
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: