Healthcare Provider Details

I. General information

NPI: 1689618720
Provider Name (Legal Business Name): MARY-ELLIN MOORE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 LITTLEFIELD RD
NEWTON MA
02459-3010
US

IV. Provider business mailing address

48 MAVERICK ST
DEDHAM MA
02026-2436
US

V. Phone/Fax

Practice location:
  • Phone: 617-928-1530
  • Fax: 617-928-1531
Mailing address:
  • Phone: 781-326-8193
  • Fax: 781-326-8193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number160595
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: