Healthcare Provider Details

I. General information

NPI: 1093745317
Provider Name (Legal Business Name): HEIDI BETH NIELL PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 10/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 BINNEY ST D1B-30 DARA FARBER CANCER INSTITUTE
BOSTON MA
02115
US

IV. Provider business mailing address

450 BROOKLINE AVE D1B-30
BOSTON MA
02215-5418
US

V. Phone/Fax

Practice location:
  • Phone: 617-525-7624
  • Fax: 617-278-6965
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1015
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: