Provider Demographics
NPI:1376081992
Name:RICHARDSON, STEPHANIE (NP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:RICHARDSON
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 1:40 ELY RD
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-5112
Mailing Address - Country:US
Mailing Address - Phone:617-288-3099
Mailing Address - Fax:
Practice Address - Street 1:81 RESERVOIR DR
Practice Address - Street 2:
Practice Address - City:ATHOL
Practice Address - State:MA
Practice Address - Zip Code:01331-4901
Practice Address - Country:US
Practice Address - Phone:978-248-5135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-02
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2266383363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily