Healthcare Provider Details

I. General information

NPI: 1457130643
Provider Name (Legal Business Name): ELIZABETH MARY MCDONNELL COSMETOLOGIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2023
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1175 MAIN ST STE 9
CLINTON MA
01510-1130
US

IV. Provider business mailing address

1175 MAIN ST STE 9
CLINTON MA
01510-1130
US

V. Phone/Fax

Practice location:
  • Phone: 978-733-1126
  • Fax:
Mailing address:
  • Phone: 978-733-1126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: