Provider Demographics
NPI:1801418470
Name:AZEVEDO, AMY LYN
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LYN
Last Name:AZEVEDO
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 1:150 COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-2901
Mailing Address - Country:US
Mailing Address - Phone:617-323-9500
Mailing Address - Fax:
Practice Address - Street 1:116 LONG POND RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-2663
Practice Address - Country:US
Practice Address - Phone:800-865-3384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-17
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2277133363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily