Provider Demographics
NPI:1033185640
Name:NICKERSON-RETI, DONNAH M (MD)
Entity Type:Individual
Prefix:DR
First Name:DONNAH
Middle Name:M
Last Name:NICKERSON-RETI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 FIFER LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-1225
Mailing Address - Country:US
Mailing Address - Phone:781-308-1600
Mailing Address - Fax:
Practice Address - Street 1:55 FIFER LN
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-1225
Practice Address - Country:US
Practice Address - Phone:781-308-1600
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA798712084P0005X, 2084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0005XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurodevelopmental Disabilities
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
BN4238691OtherDEA #
MANIA22766Medicare ID - Type Unspecified
BN4238691OtherDEA #