Healthcare Provider Details

I. General information

NPI: 1245368505
Provider Name (Legal Business Name): DANGUOLE DUOBA MAXWELL RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 QUINCY ST
BROCKTON MA
02302-2988
US

IV. Provider business mailing address

165 QUINCY ST
BROCKTON MA
02302-2988
US

V. Phone/Fax

Practice location:
  • Phone: 508-897-2100
  • Fax: 508-586-5117
Mailing address:
  • Phone: 508-897-2100
  • Fax: 508-586-5117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number185896
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: