1255379103 NPI number — MS. KARI CRETELLA NICKOU RN, MSN,CS

Table of content: MS. KARI CRETELLA NICKOU RN, MSN,CS (NPI 1255379103)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255379103 NPI number — MS. KARI CRETELLA NICKOU RN, MSN,CS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRETELLA NICKOU
Provider First Name:
KARI
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RN, MSN,CS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CRETELLA NICKOU
Provider Other First Name:
KARI
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1255379103
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 BOSTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWBURY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01951-1602
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:
21 PLEASANT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWBURYPORT
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01950-2619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-843-1801
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/03/2006

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: 364SP0809X , with the licence number:  RN169922 , 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: 110110173A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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