Provider Demographics
NPI:1891367405
Name:SPASARO, NICOLE ASHLEY
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ASHLEY
Last Name:SPASARO
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:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:291 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-3643
Practice Address - Country:US
Practice Address - Phone:508-792-1788
Practice Address - Fax:508-754-5109
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2024-01-25
Deactivation Date:2021-11-09
Deactivation Code:
Reactivation Date:2021-12-30
Provider Licenses
StateLicense IDTaxonomies
MARN2307153363L00000X
MA1891367405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner