Healthcare Provider Details

I. General information

NPI: 1821683780
Provider Name (Legal Business Name): CHARLOTTE MARIE HOLLERAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2021
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 FELLSWAY W
MEDFORD MA
02155-1849
US

IV. Provider business mailing address

611 FELLSWAY W
MEDFORD MA
02155-1849
US

V. Phone/Fax

Practice location:
  • Phone: 781-498-8221
  • Fax:
Mailing address:
  • Phone: 781-498-8221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN277786
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberRN277786
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: