Healthcare Provider Details

I. General information

NPI: 1619953098
Provider Name (Legal Business Name): JENNIFER GONDELMAN APRN, BC, RNCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 10/24/2020
Certification Date: 10/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 HIGHLAND ST
MILTON MA
02186-4432
US

IV. Provider business mailing address

324 HIGHLAND ST
MILTON MA
02186-4432
US

V. Phone/Fax

Practice location:
  • Phone: 617-690-2520
  • Fax: 617-298-2607
Mailing address:
  • Phone: 617-650-2520
  • Fax: 617-298-2607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number250606
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: