Provider Demographics
NPI:1598974222
Name:SHERWIN, AMY JEAN (COTA)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:JEAN
Last Name:SHERWIN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MISS
Other - First Name:AMY
Other - Middle Name:JEAN
Other - Last Name:DOHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:72 GRIDLEY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-1015
Mailing Address - Country:US
Mailing Address - Phone:617-479-1836
Mailing Address - Fax:
Practice Address - Street 1:72 GRIDLEY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-1015
Practice Address - Country:US
Practice Address - Phone:617-479-1836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA958314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility