Healthcare Provider Details

I. General information

NPI: 1669960274
Provider Name (Legal Business Name): MICHELLE DEDON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

471 CENTER ST
LUDLOW MA
01056-2733
US

IV. Provider business mailing address

360 US HIGHWAY 1 BYP UNIT 102
PORTSMOUTH NH
03801-7105
US

V. Phone/Fax

Practice location:
  • Phone: 413-625-3500
  • Fax: 413-625-3655
Mailing address:
  • Phone: 603-410-6700
  • Fax: 603-309-9601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN262213
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number262213
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: