Provider Demographics
NPI:1326459801
Name:FALLON, AMANDA (MSN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:FALLON
Suffix:
Gender:F
Credentials:MSN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 MADISON PL
Mailing Address - Street 2:
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01772-2143
Mailing Address - Country:US
Mailing Address - Phone:978-929-9555
Mailing Address - Fax:
Practice Address - Street 1:792 MAIN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MA
Practice Address - Zip Code:01510-1608
Practice Address - Country:US
Practice Address - Phone:978-368-7631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-18
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN22884032163WE0003X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency