Basic Information
| Provider Information | |||||||||
| NPI: | 1043701998 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GENDREAU | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | ALYSE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 PARADISE RD | ||||||||
| Address2: | |||||||||
| City: | SWAMPSCOTT | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019072948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7815962000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 250 PARADISE RD | ||||||||
| Address2: | |||||||||
| City: | SWAMPSCOTT | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019072948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7815962000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2018 | ||||||||
| LastUpdateDate: | 06/18/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 06/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN2321725 | MA | N | Nursing Service Providers | Registered Nurse | 363LF0000X | RN2321725 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.