Healthcare Provider Details

I. General information

NPI: 1447479985
Provider Name (Legal Business Name): EKATERINI POULAKOS APRN,BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 MORTON ST
JAMAICA PLAIN MA
02130-3735
US

IV. Provider business mailing address

11 ASHLAND ST
MEDFORD MA
02155-3214
US

V. Phone/Fax

Practice location:
  • Phone: 617-626-9558
  • Fax: 617-626-9591
Mailing address:
  • Phone: 781-395-3870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number142122
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: