Provider Demographics
NPI:1205171444
Name:CAPOTOSTO, MELISSA KRISTEN (NP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:KRISTEN
Last Name:CAPOTOSTO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:KRISTEN
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:800 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1552
Mailing Address - Country:US
Mailing Address - Phone:617-636-5000
Mailing Address - Fax:
Practice Address - Street 1:250 GREEN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440-1396
Practice Address - Country:US
Practice Address - Phone:978-632-6880
Practice Address - Fax:978-632-5937
Is Sole Proprietor?:No
Enumeration Date:2012-11-28
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2261657363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA003269001Medicare PIN