Healthcare Provider Details

I. General information

NPI: 1467118257
Provider Name (Legal Business Name): JILL ROTHWELL STEVENS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2021
Last Update Date: 11/16/2021
Certification Date: 11/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SOUTH ST
SOUTHBRIDGE MA
01550-4051
US

IV. Provider business mailing address

1420 ROUTE 169
WOODSTOCK CT
06281-1437
US

V. Phone/Fax

Practice location:
  • Phone: 508-765-9771
  • Fax:
Mailing address:
  • Phone: 860-428-9724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2263625
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: