Provider Demographics
NPI:1467447482
Name:DEFOREST, NANCY E (NP)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:E
Last Name:DEFOREST
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:77 WARREN ST
Mailing Address - Street 2:ROOM 339
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-3601
Mailing Address - Country:US
Mailing Address - Phone:617-562-5359
Mailing Address - Fax:617-562-5415
Practice Address - Street 1:24 COMMON STREET,
Practice Address - Street 2:SUITE 1
Practice Address - City:WRENTHAM
Practice Address - State:MA
Practice Address - Zip Code:02093
Practice Address - Country:US
Practice Address - Phone:508-384-2223
Practice Address - Fax:508-384-0066
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA107372363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0319040Medicaid
Q10498Medicare UPIN
MANP4487Medicare ID - Type Unspecified