=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154034437
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNA ANUSH GRIGORIAN NURSE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2023
-----------------------------------------------------
Last Update Date | 01/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 VFW PKWY
-----------------------------------------------------
City | WEST ROXBURY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02132-4927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 857-203-6313
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 68 NEEDHAM ST
-----------------------------------------------------
City | DEDHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02026-1439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-678-5752
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 5242949
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------