Healthcare Provider Details

I. General information

NPI: 1962009852
Provider Name (Legal Business Name): GERARD PHILIP EYSSALLENNE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2020
Last Update Date: 10/05/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 HAVERHILL STREET
LAWRENCE MA
01841
US

IV. Provider business mailing address

PO BOX 211
METHUEN MA
01844-0211
US

V. Phone/Fax

Practice location:
  • Phone: 978-686-0090
  • Fax:
Mailing address:
  • Phone: 978-943-1049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN234932
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: