Healthcare Provider Details

I. General information

NPI: 1558136622
Provider Name (Legal Business Name): ERIN MARIE HENNESSY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2023
Last Update Date: 11/20/2023
Certification Date: 11/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 WILLOW ST
WEST ROXBURY MA
02132-1537
US

IV. Provider business mailing address

10 CHAPEL WAY
WOBURN MA
01801-4724
US

V. Phone/Fax

Practice location:
  • Phone: 617-469-3080
  • Fax: 617-469-3085
Mailing address:
  • Phone: 617-620-2799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number251267
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: