Provider Demographics
NPI:1558930016
Name:GEORGEON-ETIENNE, MODELEINE
Entity Type:Individual
Prefix:MRS
First Name:MODELEINE
Middle Name:
Last Name:GEORGEON-ETIENNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-4836
Mailing Address - Country:US
Mailing Address - Phone:617-823-5534
Mailing Address - Fax:
Practice Address - Street 1:531 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-4836
Practice Address - Country:US
Practice Address - Phone:617-823-5534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0000363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology