Healthcare Provider Details

I. General information

NPI: 1578179040
Provider Name (Legal Business Name): VIVIAN ELLEN DONAHUE RN, CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2696
US

IV. Provider business mailing address

432 WINTHROP ST
MEDFORD MA
02155-2330
US

V. Phone/Fax

Practice location:
  • Phone: 617-724-8771
  • Fax: 617-724-4450
Mailing address:
  • Phone: 617-448-0948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN155844
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: