Provider Demographics
NPI:1164406997
Name:DEFORT, DALE KAREN (RN CS)
Entity Type:Individual
Prefix:MS
First Name:DALE
Middle Name:KAREN
Last Name:DEFORT
Suffix:
Gender:F
Credentials:RN CS
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Mailing Address - Street 1:30 FEDERAL ST
Mailing Address - Street 2:STE B
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970
Mailing Address - Country:US
Mailing Address - Phone:978-740-9590
Mailing Address - Fax:978-744-5486
Practice Address - Street 1:30 FEDERAL ST
Practice Address - Street 2:STE B
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970
Practice Address - Country:US
Practice Address - Phone:978-740-9590
Practice Address - Fax:978-744-5486
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA110410364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1898493Medicaid
MA1898493Medicaid