Healthcare Provider Details

I. General information

NPI: 1265355119
Provider Name (Legal Business Name): PROSSY NANTAMBISTMARIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

879 LEXINGTON STREET 14B
WALTHAM MA
02452
US

IV. Provider business mailing address

879 LEXINGTON STREET 14B
WALTHAM MA
02452
US

V. Phone/Fax

Practice location:
  • Phone: 857-417-7029
  • Fax: 857-417-7029
Mailing address:
  • Phone: 857-417-7029
  • Fax: 857-417-7029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLNNE1004443
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: