Healthcare Provider Details

I. General information

NPI: 1578385498
Provider Name (Legal Business Name): SUSAN J AVEDISSIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2024
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 MILL ST APT 2301
HANOVER MA
02339-1727
US

IV. Provider business mailing address

80 MILL ST APT 2301
HANOVER MA
02339-1727
US

V. Phone/Fax

Practice location:
  • Phone: 508-509-7349
  • Fax:
Mailing address:
  • Phone: 508-509-7349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-305651
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: