Healthcare Provider Details

I. General information

NPI: 1902100324
Provider Name (Legal Business Name): JILL ELIZABETH DECOLOGERO ANP-BC, MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2010
Last Update Date: 12/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 WOODLAND RD STE 322
STONEHAM MA
02180-1713
US

IV. Provider business mailing address

3 WOODLAND RD STE 322
STONEHAM MA
02180-1713
US

V. Phone/Fax

Practice location:
  • Phone: 781-662-2243
  • Fax: 781-662-4878
Mailing address:
  • Phone: 781-662-2243
  • Fax: 781-662-4878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN267529
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: