Provider Demographics
NPI:1184394967
Name:ZOLFONOON, GIANCARLO D (PMHNP)
Entity type:Individual
Prefix:MR
First Name:GIANCARLO
Middle Name:D
Last Name:ZOLFONOON
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 HARVARD ST APT 1
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02124-2716
Mailing Address - Country:US
Mailing Address - Phone:617-797-4209
Mailing Address - Fax:
Practice Address - Street 1:165 QUINCY ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-2988
Practice Address - Country:US
Practice Address - Phone:508-897-2058
Practice Address - Fax:508-897-2223
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-14
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA390200000X
MARN2270000363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program