Healthcare Provider Details

I. General information

NPI: 1033185640
Provider Name (Legal Business Name): DONNAH M NICKERSON-RETI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FIFER LN
LEXINGTON MA
02420-1225
US

IV. Provider business mailing address

55 FIFER LN
LEXINGTON MA
02420-1225
US

V. Phone/Fax

Practice location:
  • Phone: 781-308-1600
  • Fax:
Mailing address:
  • Phone: 781-308-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0005X
TaxonomyNeurodevelopmental Disabilities Physician
License Number79871
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number79871
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number79871
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: