Provider Demographics
NPI:1578254769
Name:POLVERE, JUSTINA
Entity Type:Individual
Prefix:
First Name:JUSTINA
Middle Name:
Last Name:POLVERE
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 1:18 KEYES DR APT 12
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-8020
Mailing Address - Country:US
Mailing Address - Phone:339-235-8349
Mailing Address - Fax:
Practice Address - Street 1:18 KEYES DR APT 12
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-8020
Practice Address - Country:US
Practice Address - Phone:339-235-8349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MACNM04708367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife