Provider Demographics
NPI:1568217776
Name:NOLAN, JACQUELYN ROSE
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:ROSE
Last Name:NOLAN
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 1:15 BOUTWELL ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02122-2513
Mailing Address - Country:US
Mailing Address - Phone:339-933-9443
Mailing Address - Fax:
Practice Address - Street 1:2 POND PARK RD
Practice Address - Street 2:
Practice Address - City:HINGHAM
Practice Address - State:MA
Practice Address - Zip Code:02043-4347
Practice Address - Country:US
Practice Address - Phone:781-337-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2325565363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily