Provider Demographics
NPI:1093826372
Name:RUTTEMAN, DOMINIQUE (RN, CS)
Entity Type:Individual
Prefix:MS
First Name:DOMINIQUE
Middle Name:
Last Name:RUTTEMAN
Suffix:
Gender:F
Credentials:RN, CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 LINDALL ST
Mailing Address - Street 2:CENTER FOR HEALTHY AGING
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-2121
Mailing Address - Country:US
Mailing Address - Phone:978-774-4400
Mailing Address - Fax:978-750-6988
Practice Address - Street 1:75 LINDALL ST
Practice Address - Street 2:CENTER FOR HEALTHY AGING
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-2121
Practice Address - Country:US
Practice Address - Phone:978-774-4400
Practice Address - Fax:978-750-6988
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN131934364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult