Provider Demographics
NPI:1790926624
Name:SPIDLE, JENNIFER (RN, PNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SPIDLE
Suffix:
Gender:F
Credentials:RN, PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 L ST # 3
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-4213
Mailing Address - Country:US
Mailing Address - Phone:617-632-4992
Mailing Address - Fax:617-632-5710
Practice Address - Street 1:450 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5418
Practice Address - Country:US
Practice Address - Phone:617-632-4992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-24
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA266853163W00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse