Healthcare Provider Details

I. General information

NPI: 1760889091
Provider Name (Legal Business Name): SUSAN STENGREVICS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SUSAN SUMNER

II. Dates (important events)

Enumeration Date: 12/02/2014
Last Update Date: 12/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

1184 WESTFORD ST
CARLISLE MA
01741-1403
US

V. Phone/Fax

Practice location:
  • Phone: 617-724-4910
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number150309
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number150309
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: