Healthcare Provider Details

I. General information

NPI: 1699215665
Provider Name (Legal Business Name): MRS. SANDRA OUELLETTE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2017
Last Update Date: 04/23/2020
Certification Date: 04/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MILL RD STE 120
FAIRHAVEN MA
02719-5252
US

IV. Provider business mailing address

200 MILL RD STE 180
FAIRHAVEN MA
02719-5255
US

V. Phone/Fax

Practice location:
  • Phone: 508-973-3200
  • Fax: 508-973-3215
Mailing address:
  • Phone: 508-973-2000
  • Fax: 508-973-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN200112
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: