Healthcare Provider Details

I. General information

NPI: 1215628664
Provider Name (Legal Business Name): STACY JILL OSTERHOUDT ACNPC-AG,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2023
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 ALBANY STREET, SUITE 7B SHAPIRO BLDG.
BOSTON MA
02118
US

IV. Provider business mailing address

960 MASSACHUSETTS AVENUE FL 2
BOSTON MA
02118-2690
US

V. Phone/Fax

Practice location:
  • Phone: 617-638-8456
  • Fax: 617-638-8465
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN2389809
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberRN2389809
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: