Healthcare Provider Details

I. General information

NPI: 1932928769
Provider Name (Legal Business Name): AMY VAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 ALBANY ST
BOSTON MA
02118-3549
US

IV. Provider business mailing address

519 LOWELL ST
LEXINGTON MA
02420-2242
US

V. Phone/Fax

Practice location:
  • Phone: 508-369-0641
  • Fax:
Mailing address:
  • Phone: 508-369-0641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2303524
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: