Healthcare Provider Details

I. General information

NPI: 1679270417
Provider Name (Legal Business Name): MINA R ETEDALI RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2023
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 LIBERTY ST
DANVERS MA
01923-3323
US

IV. Provider business mailing address

66 LIBERTY ST
DANVERS MA
01923-3323
US

V. Phone/Fax

Practice location:
  • Phone: 978-380-2432
  • Fax:
Mailing address:
  • Phone: 978-380-2432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2356171
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberRN2356171
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number2356171
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: