Provider Demographics
NPI:1316411481
Name:THEODORIS, CASSANDRA (NP)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:THEODORIS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:CASSANDRA
Other - Middle Name:
Other - Last Name:DESJARDINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1440 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-6112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5521
Practice Address - Country:US
Practice Address - Phone:508-894-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2312573363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner