Healthcare Provider Details

I. General information

NPI: 1164397170
Provider Name (Legal Business Name): NATHAN POMERLEAU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2025
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3816 DODSON CHAPEL RD APT 601
HERMITAGE TN
37076-3790
US

IV. Provider business mailing address

3816 DODSON CHAPEL RD APT 601
HERMITAGE TN
37076-3790
US

V. Phone/Fax

Practice location:
  • Phone: 413-455-4664
  • Fax:
Mailing address:
  • Phone: 413-455-4664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number260549
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: