Healthcare Provider Details

I. General information

NPI: 1497744981
Provider Name (Legal Business Name): YANA ANTONELLIS N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545A CENTRE ST
JAMAICA PLAIN MA
02130-2061
US

IV. Provider business mailing address

545A CENTRE ST
JAMAICA PLAIN MA
02130-2061
US

V. Phone/Fax

Practice location:
  • Phone: 617-522-5464
  • Fax: 617-524-2966
Mailing address:
  • Phone: 617-522-5464
  • Fax: 617-524-2966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number233109
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: