Healthcare Provider Details

I. General information

NPI: 1174274385
Provider Name (Legal Business Name): JAILENE ANGELICA ROMAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2022
Last Update Date: 05/30/2026
Certification Date: 05/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CANAL ST
SALEM MA
01970-4558
US

IV. Provider business mailing address

300 CANAL ST
SALEM MA
01970-4558
US

V. Phone/Fax

Practice location:
  • Phone: 978-740-2912
  • Fax:
Mailing address:
  • Phone: 978-740-2912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2351266
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2351266
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: