Provider Demographics
NPI:1689090557
Name:MEDEIROS, STEPHANIE (RN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MEDEIROS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 HAMPSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-1306
Mailing Address - Country:US
Mailing Address - Phone:617-575-5570
Mailing Address - Fax:
Practice Address - Street 1:237 HAMPSHIRE ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-1306
Practice Address - Country:US
Practice Address - Phone:617-575-5570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2273604261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care