Healthcare Provider Details

I. General information

NPI: 1972044980
Provider Name (Legal Business Name): IRIS VICENCIO-RASKU NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2017
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S HUNTINGTON AVE BLDG 9
JAMAICA PLAIN MA
02130-4817
US

IV. Provider business mailing address

150 S HUNTINGTON AVE BLDG 9
JAMAICA PLAIN MA
02130-4817
US

V. Phone/Fax

Practice location:
  • Phone: 413-584-4040
  • Fax: 857-364-6003
Mailing address:
  • Phone: 857-364-6003
  • Fax: 857-364-2803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN276885
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN276885
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN276885
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: