Provider Demographics
NPI:1124016142
Name:KLEMENTS, ELIZABETH MELVILLE (PNP)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:MELVILLE
Last Name:KLEMENTS
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:MELVILLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1029 PLEASANT ST
Mailing Address - Street 2:BRIDGEWATER PEDIATRICS
Mailing Address - City:BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02324
Mailing Address - Country:US
Mailing Address - Phone:508-697-8116
Mailing Address - Fax:508-697-8117
Practice Address - Street 1:1029 PLEASANT ST
Practice Address - Street 2:BRIDGEWATER PEDIATRICS
Practice Address - City:BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02324
Practice Address - Country:US
Practice Address - Phone:508-697-8116
Practice Address - Fax:508-697-8117
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA137478363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0378950Medicaid
P05163Medicare UPIN
MANP2397Medicare ID - Type Unspecified