Healthcare Provider Details

I. General information

NPI: 1134322936
Provider Name (Legal Business Name): LOUISA LEA JELLISON RNC, MSN, NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 WASHINGTON ST BOX # 300
BOSTON MA
02111-1526
US

IV. Provider business mailing address

15 CARRIAGE LN
READING MA
01867-1373
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-5008
  • Fax: 617-636-9653
Mailing address:
  • Phone: 781-942-0115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number115843
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: