Provider Demographics
NPI:1942240197
Name:VAN ETTEN, DEBORAH A (MS,APRN,BC,CS)
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:A
Last Name:VAN ETTEN
Suffix:
Gender:F
Credentials:MS,APRN,BC,CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LORING RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-6907
Mailing Address - Country:US
Mailing Address - Phone:781-861-1752
Mailing Address - Fax:
Practice Address - Street 1:90 CONCORD AVE
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478-4046
Practice Address - Country:US
Practice Address - Phone:617-251-6896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA155485364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health