Healthcare Provider Details

I. General information

NPI: 1356176481
Provider Name (Legal Business Name): SAMANTHA NORTELUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2024
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 W SQUANTUM ST
NORTH QUINCY MA
02171-2122
US

IV. Provider business mailing address

110 W SQUANTUM ST
NORTH QUINCY MA
02171-2122
US

V. Phone/Fax

Practice location:
  • Phone: 617-376-3000
  • Fax:
Mailing address:
  • Phone: 617-376-3000
  • Fax: 617-774-1905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberRN2379841
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2379841
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: