Provider Demographics
NPI:1013315928
Name:MOTTOLA, AUDREY
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:MOTTOLA
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 1:266 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:SAUGUS
Mailing Address - State:MA
Mailing Address - Zip Code:01906-3037
Mailing Address - Country:US
Mailing Address - Phone:781-233-6830
Mailing Address - Fax:
Practice Address - Street 1:266 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SAUGUS
Practice Address - State:MA
Practice Address - Zip Code:01906-3037
Practice Address - Country:US
Practice Address - Phone:781-233-6830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3436172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker