1457960304 NPI number — LORIAN CANDACE DE OLIVEIRA AGACNP-BC

Table of content: LORIAN CANDACE DE OLIVEIRA AGACNP-BC (NPI 1457960304)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457960304 NPI number — LORIAN CANDACE DE OLIVEIRA AGACNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE OLIVEIRA
Provider First Name:
LORIAN
Provider Middle Name:
CANDACE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AGACNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JENKINS
Provider Other First Name:
LORIAN
Provider Other Middle Name:
CANDACE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
CNP
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1457960304
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 BROOKLINE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02215-5400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
917-796-3392
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16 WYOMING ST UNIT 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02121-1205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-796-3392
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  RN2291496 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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