Healthcare Provider Details

I. General information

NPI: 1568013175
Provider Name (Legal Business Name): MICHAEL DOMENIC DEFABRIZIO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2019
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 HARRY KEMP WAY
PROVINCETOWN MA
02657-1618
US

IV. Provider business mailing address

PO BOX 2796
ORLEANS MA
02653-6796
US

V. Phone/Fax

Practice location:
  • Phone: 508-487-9395
  • Fax: 508-487-6298
Mailing address:
  • Phone: 508-487-9395
  • Fax: 508-487-6298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11026323
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2301292
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: