Healthcare Provider Details

I. General information

NPI: 1336696053
Provider Name (Legal Business Name): COLETTE MONTONI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2016
Last Update Date: 02/24/2022
Certification Date: 02/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BLACKBURN DR
GLOUCESTER MA
01930-2237
US

IV. Provider business mailing address

6 TRAVERSE ST
GLOUCESTER MA
01930-3232
US

V. Phone/Fax

Practice location:
  • Phone: 978-281-1500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAG0716105
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN2263095
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: