Healthcare Provider Details

I. General information

NPI: 1568169324
Provider Name (Legal Business Name): CHRISTINA MARIE GAUTREAU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2023
Last Update Date: 02/13/2023
Certification Date: 02/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 COMMONWEALTH AVE
BOSTON MA
02215-1001
US

IV. Provider business mailing address

18 HALLAM ST APT 1
DORCHESTER MA
02125-4606
US

V. Phone/Fax

Practice location:
  • Phone: 617-295-7235
  • Fax:
Mailing address:
  • Phone: 978-833-3552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License NumberRN2348194
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: