Healthcare Provider Details

I. General information

NPI: 1376144741
Provider Name (Legal Business Name): SUHAITI LEE VILLA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2020
Last Update Date: 01/31/2023
Certification Date: 01/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MARSTON ST STE 301
LAWRENCE MA
01841-2358
US

IV. Provider business mailing address

15 RIDGE ST
METHUEN MA
01844-3122
US

V. Phone/Fax

Practice location:
  • Phone: 978-946-8550
  • Fax:
Mailing address:
  • Phone: 978-420-2599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2277963
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberRN2277963
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: