Healthcare Provider Details

I. General information

NPI: 1245957349
Provider Name (Legal Business Name): ISABELLA RAVANESI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2022
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 W BROADWAY
BOSTON MA
02127-2245
US

IV. Provider business mailing address

2 CHISHOLM LN
BOSTON MA
02131-4533
US

V. Phone/Fax

Practice location:
  • Phone: 617-269-7500
  • Fax:
Mailing address:
  • Phone: 413-351-5598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: