Healthcare Provider Details

I. General information

NPI: 1932415932
Provider Name (Legal Business Name): BARBARA GANNON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2010
Last Update Date: 08/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 DUDLEY ST
PROVIDENCE RI
02905-2401
US

IV. Provider business mailing address

18 MARTINS WAY
LINCOLN RI
02865-1304
US

V. Phone/Fax

Practice location:
  • Phone: 401-274-1100
  • Fax: 401-453-7948
Mailing address:
  • Phone: 401-334-2407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNPP25427
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberNPP25427
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberRN200043
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: