=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639808603
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATIE DYMPNA PATRICIA IADONISI MSN, A-GNP-C, OCN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2022
-----------------------------------------------------
Last Update Date | 02/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 COLUMBIAN ST
-----------------------------------------------------
City | SOUTH WEYMOUTH
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02190-1601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-624-4800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 COLUMBIAN ST
-----------------------------------------------------
City | SOUTH WEYMOUTH
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02190-1601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 5016311
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 5016311
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | 5016311
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | RN2361573
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------