Provider Demographics
NPI:1295855450
Name:MORTELLITE, JAMIE C (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:JAMIE
Middle Name:C
Last Name:MORTELLITE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 LOWELL RD
Mailing Address - Street 2:
Mailing Address - City:NORTH READING
Mailing Address - State:MA
Mailing Address - Zip Code:01864-1632
Mailing Address - Country:US
Mailing Address - Phone:781-910-0322
Mailing Address - Fax:617-667-9922
Practice Address - Street 1:330 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5400
Practice Address - Country:US
Practice Address - Phone:617-667-1949
Practice Address - Fax:617-667-9922
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA254663363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA94036OtherFALLON
MANP4995OtherBLUE CARE 65
MA21258700817OtherBEECH STREET
MA0703095Medicaid
MANP4995OtherBLUE CARE ELECT
MANP4995Medicare ID - Type Unspecified
MA0703095Medicaid