Provider Demographics
NPI:1861439390
Name:VIVENZIO, KAREN R (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:R
Last Name:VIVENZIO
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:R
Other - Last Name:DUDENHOEFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:1400 VFW PKWY
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-4927
Mailing Address - Country:US
Mailing Address - Phone:857-203-6871
Mailing Address - Fax:
Practice Address - Street 1:1400 VFW PARKWAY
Practice Address - Street 2:WEST ROXBURY VETERANS ADMINISTRATION
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132
Practice Address - Country:US
Practice Address - Phone:857-203-6871
Practice Address - Fax:857-203-5738
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN281298L363LA2100X
PAVP005145B363LA2100X
NY5155791363LA2100X
NYF3332551363LA2100X
MA263669363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care