Provider Demographics
NPI:1558886457
Name:DOUGLAS VILLARI, CHEYENNE (MSN, RN, CPNP-PC)
Entity Type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:
Last Name:DOUGLAS VILLARI
Suffix:
Gender:F
Credentials:MSN, RN, CPNP-PC
Other - Prefix:
Other - First Name:CHEYENNE -AUTUMN
Other - Middle Name:MACKENZIE
Other - Last Name:DOUGLAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, RN, CPNP-PC
Mailing Address - Street 1:300 LONGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:617-355-6000
Mailing Address - Fax:
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-11
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7144363LP0200X
NY382889363LP0200X
MARN2310376363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05384905Medicaid