1104440908 NPI number — JOELLE GRACE SULISTIO FNP

Table of content: JOELLE GRACE SULISTIO FNP (NPI 1104440908)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104440908 NPI number — JOELLE GRACE SULISTIO FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULISTIO
Provider First Name:
JOELLE
Provider Middle Name:
GRACE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SULISTIO
Provider Other First Name:
JOELLE
Provider Other Middle Name:
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:
1104440908
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
960 MASSACHUSETTS AVENUE
Provider Second Line Business Mailing Address:
FL 2
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02118-2690
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
732 HARRISON AVE, FL 2
Provider Second Line Business Practice Location Address:
PRESTON BLDG
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02118-2309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-638-7470
Provider Business Practice Location Address Fax Number:
617-638-7449
Provider Enumeration Date:
06/08/2020

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: 363LF0000X , with the licence number:  RN2330392 , 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)

  • Identifier: 110164332A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3136892 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".




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