Provider Demographics
NPI:1952919623
Name:DOMENICHELLA, BEATRICE GLEN (CNP)
Entity Type:Individual
Prefix:
First Name:BEATRICE
Middle Name:GLEN
Last Name:DOMENICHELLA
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BICENTENNIAL AVE
Mailing Address - Street 2:
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-5227
Mailing Address - Country:US
Mailing Address - Phone:978-870-6930
Mailing Address - Fax:
Practice Address - Street 1:5 BICENTENNIAL AVE
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-5227
Practice Address - Country:US
Practice Address - Phone:978-870-6930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN173210363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner