1093057580 NPI number — MS. JENNIFER MASSARELLI NURSE PRACTITIONER

Table of content: MS. JENNIFER MASSARELLI NURSE PRACTITIONER (NPI 1093057580)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093057580 NPI number — MS. JENNIFER MASSARELLI NURSE PRACTITIONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MASSARELLI
Provider First Name:
JENNIFER
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
NURSE PRACTITIONER
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HALL
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093057580
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 LAKE AVE N
Provider Second Line Business Mailing Address:
UMASS MEMORIAL MEDICAL CENTER, PSYCHIATRY
Provider Business Mailing Address City Name:
WORCESTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01655-0002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-334-3562
Provider Business Mailing Address Fax Number:
508-421-1000

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2215 FULLER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANN ARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48105-2303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-769-7100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/22/2013

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: 163WP0808X , with the licence number:  276298 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: RN276298 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: 4704344082 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 276298 . This is a "LICENSE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 4704344082 . This is a "LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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