Provider Demographics
NPI:1124592324
Name:HIPPOLYTE, PRIYA MARIE
Entity Type:Individual
Prefix:
First Name:PRIYA
Middle Name:MARIE
Last Name:HIPPOLYTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 GRANITE AVE STE 260
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-4381
Mailing Address - Country:US
Mailing Address - Phone:617-369-7136
Mailing Address - Fax:617-369-7136
Practice Address - Street 1:2 GRANITE AVE STE 260
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-4381
Practice Address - Country:US
Practice Address - Phone:617-369-7136
Practice Address - Fax:617-369-7136
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2287823363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1124592324OtherNPI