MEDICARE: HEENA NISSARALY DNP, RN, AGNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN2349337	MA
2	363L00000X	Nurse Practitioner	AG07250146	MA

General Provider Information

NPI Number	:	1013890433
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEENA NISSARALY DNP, RN, AGNP-C

Provider Business Mailing Address
First Line	:	3297 WASHINGTON ST
Second Line	:
City	:	JAMAICA PLAIN
State	:	MA
Zip	:	02130-2655
Country	:	US
Telephone Number	:	617-763-3518
Fax Number	:

Provider Business Practice Location Address
First Line	:	3297 WASHINGTON ST
Second Line	:
City	:	JAMAICA PLAIN
State	:	MA
Zip	:	02130-2655
Country	:	US
Telephone Number	:	617-522-4700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2025
Last Update Date	:	02/04/2026

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