Healthcare Provider Details

I. General information

NPI: 1700322674
Provider Name (Legal Business Name): ROSALIND GENDREAU RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2017
Last Update Date: 12/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 NEWTON ST
SOUTHBOROUGH MA
01772-1215
US

IV. Provider business mailing address

5 NEPONSET ST FL STREET2
WORCESTER MA
01606-2714
US

V. Phone/Fax

Practice location:
  • Phone: 508-460-3190
  • Fax: 508-460-3279
Mailing address:
  • Phone: 508-460-3190
  • Fax: 508-460-3279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number256701
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN256701
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: