Provider Demographics
NPI:1124222880
Name:DASTOUS, REINA MARIE (CNM)
Entity Type:Individual
Prefix:MS
First Name:REINA
Middle Name:MARIE
Last Name:DASTOUS
Suffix:
Gender:F
Credentials:CNM
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Mailing Address - Street 1:LAHEY CLINIC INC., PROVIDER ENROLLMENT DEPARTMENT
Mailing Address - Street 2:41 MALL ROAD
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805
Mailing Address - Country:US
Mailing Address - Phone:781-744-8085
Mailing Address - Fax:781-744-5433
Practice Address - Street 1:85 HERRICK ST
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-1790
Practice Address - Country:US
Practice Address - Phone:978-927-7880
Practice Address - Fax:978-524-6082
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2018-02-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA245530367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANPP-000Medicare UPIN