Healthcare Provider Details

I. General information

NPI: 1265420186
Provider Name (Legal Business Name): NICOLE DUANE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE PHILLIPS RN, NP

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 08/06/2021
Certification Date: 08/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 SUMMER ST
MAYNARD MA
01754-2226
US

IV. Provider business mailing address

84 SUMMER ST
MAYNARD MA
01754-2226
US

V. Phone/Fax

Practice location:
  • Phone: 978-793-3498
  • Fax:
Mailing address:
  • Phone: 978-793-3498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number193980
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number193980
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: