1184065443 NPI number — ELLEN GRACE CALLAHAN CPNP

Table of content: ELLEN GRACE CALLAHAN CPNP (NPI 1184065443)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184065443 NPI number — ELLEN GRACE CALLAHAN CPNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CALLAHAN
Provider First Name:
ELLEN
Provider Middle Name:
GRACE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CPNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRIFFIN
Provider Other First Name:
ELLEN
Provider Other Middle Name:
GRACE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1184065443
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
180 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANDOVER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01810-4166
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:
180 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANDOVER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01810-4166
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-749-4460
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/15/2013

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: 363LP0200X , with the licence number:  2277495 , 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)