Healthcare Provider Details

I. General information

NPI: 1326083551
Provider Name (Legal Business Name): TARA L GONSALVES NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DEL POND DR
CANTON MA
02021-2759
US

IV. Provider business mailing address

39 PARSONS WALK
BERKLEY MA
02779-1628
US

V. Phone/Fax

Practice location:
  • Phone: 781-821-3210
  • Fax:
Mailing address:
  • Phone: 508-822-2979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number232268
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: