Healthcare Provider Details

I. General information

NPI: 1649372244
Provider Name (Legal Business Name): ELIZABETH N TANNEBRING MSN, CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE CCS CLINIC
BOSTON MA
02115-5724
US

IV. Provider business mailing address

66 WOBURN ST
ANDOVER MA
01810-6076
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-2823
  • Fax: 617-730-0621
Mailing address:
  • Phone: 978-623-0972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number200437
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: