Provider Demographics
NPI:1720461957
Name:SUPER, DINAH (NP)
Entity Type:Individual
Prefix:
First Name:DINAH
Middle Name:
Last Name:SUPER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2060
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:354 WAVERLY ST
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-7079
Practice Address - Country:US
Practice Address - Phone:508-370-0113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2272664163WC1500X
NY22 687634163WP2201X
NYRN2272664390200000X
MARN2272604363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program