Provider Demographics
NPI:1649845355
Name:DIMODICA, TERESA ANN (MSN, NP-C, RN)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:ANN
Last Name:DIMODICA
Suffix:
Gender:F
Credentials:MSN, NP-C, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 DESOTO RD
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-6004
Mailing Address - Country:US
Mailing Address - Phone:617-910-7970
Mailing Address - Fax:
Practice Address - Street 1:1 HARBORSIDE DR
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02128-2907
Practice Address - Country:US
Practice Address - Phone:844-977-3725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2267894363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner