Provider Demographics
NPI:1326717612
Name:RAWAN, JACQUELYN (NP)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:RAWAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 KINNICUTT RD
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01602-1548
Mailing Address - Country:US
Mailing Address - Phone:508-439-9575
Mailing Address - Fax:
Practice Address - Street 1:700 CROWN COLONY DR
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-0924
Practice Address - Country:US
Practice Address - Phone:617-472-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7210338207R00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine