Provider Demographics
NPI:1831345990
Name:DEOLIVEIRA, GLEIDISTONEY JOSE (APRN)
Entity type:Individual
Prefix:MR
First Name:GLEIDISTONEY
Middle Name:JOSE
Last Name:DEOLIVEIRA
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 NICHOLS ROAD
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420
Mailing Address - Country:US
Mailing Address - Phone:978-878-8516
Mailing Address - Fax:978-878-8418
Practice Address - Street 1:326 NICHOLS ROAD
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420
Practice Address - Country:US
Practice Address - Phone:978-878-8440
Practice Address - Fax:978-878-8535
Is Sole Proprietor?:No
Enumeration Date:2008-08-08
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA215489163WP0808X
MARN215489163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1301071OtherGROUP MEDICAID NUMBER