Healthcare Provider Details

I. General information

NPI: 1144627829
Provider Name (Legal Business Name): ALIA CRYSTAL MACPHERSON FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2014
Last Update Date: 07/02/2021
Certification Date: 07/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BLACKBURN DR
GLOUCESTER MA
01930-2292
US

IV. Provider business mailing address

1 BLACKBURN DR
GLOUCESTER MA
01930-2292
US

V. Phone/Fax

Practice location:
  • Phone: 978-281-1500
  • Fax: 978-282-3611
Mailing address:
  • Phone: 978-281-1500
  • Fax: 978-282-3611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5991
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2305963
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: