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NPI Code Detail

MEDICARE: NICHOLE MARIE PHELPS LATENDRESSE M.A

MEDICARE: NICHOLE MARIE PHELPS LATENDRESSE M.A
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
1171M00000XCase Manager/Care Coordinator

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
16400144OTHERRIUNITED

General Provider Information

NPI Number : 1700102217
Entity Type Code : Individual
Provider Name (Legal Business Name) : NICHOLE MARIE PHELPS LATENDRESSE M.A
Provider Business Mailing Address
First Line : 328 MAIN ST
Second Line :
City : SOUTHBRIDGE
State : MA
Zip : 01550-3794
Country : US
Telephone Number : 401-338-5096
Fax Number :
Provider Business Practice Location Address
First Line : 328 MAIN ST
Second Line :
City : SOUTHBRIDGE
State : MA
Zip : 01550-3794
Country : US
Telephone Number : 508-765-9101
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/09/2010
Last Update Date : 05/10/2016

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Directions to “ NICHOLE MARIE PHELPS LATENDRESSE M.A” Practice Location

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