Healthcare Provider Details

I. General information

NPI: 1720695695
Provider Name (Legal Business Name): ELIZABETH MOYNIHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST WHITE 1
BOSTON MA
02114-2621
US

IV. Provider business mailing address

9 MARION ST
MEDFORD MA
02155-6219
US

V. Phone/Fax

Practice location:
  • Phone: 617-724-4100
  • Fax: 617-726-7415
Mailing address:
  • Phone: 860-942-9878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA8455
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: