Provider Demographics
NPI:1285685941
Name:EDITH NOURSE ROGERS MEMORIAL VAMC
Entity Type:Organization
Organization Name:EDITH NOURSE ROGERS MEMORIAL VAMC
Other - Org Name:LYNN CBOC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:DES LOGES
Authorized Official - Suffix:
Authorized Official - Credentials:MSN RN ANP
Authorized Official - Phone:1781-687-4923
Mailing Address - Street 1:7 BACON DR
Mailing Address - Street 2:
Mailing Address - City:SAUGUS
Mailing Address - State:MA
Mailing Address - Zip Code:01906-2405
Mailing Address - Country:US
Mailing Address - Phone:178-123-3463
Mailing Address - Fax:
Practice Address - Street 1:225 BOSTON ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01904-2405
Practice Address - Country:US
Practice Address - Phone:178-123-3463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA138951284300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital