1720369838 NPI number — MS. JESSALYNNE MARIE ANTILUS MA

Table of content: MS. JESSALYNNE MARIE ANTILUS MA (NPI 1720369838)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720369838 NPI number — MS. JESSALYNNE MARIE ANTILUS MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANTILUS
Provider First Name:
JESSALYNNE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BERGIN
Provider Other First Name:
JESSALYNNE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720369838
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 W PEARL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHUA
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03060-3343
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-889-6147
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 PINE STREET EXT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NASHUA
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03060-3248
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-889-6147
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/01/2011

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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