Basic Information
| Provider Information | |||||||||
| NPI: | 1124448428 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOMBROWSKI | ||||||||
| FirstName: | BETH | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | N.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HURLBURT | ||||||||
| OtherFirstName: | BETH | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | N.P. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 200 COPELAND DR | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020481225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083394144 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 200 COPELAND DR | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020481225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083394144 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2014 | ||||||||
| LastUpdateDate: | 06/23/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN2284354 | MA | N | Nursing Service Providers | Registered Nurse | 363LF0000X | RN2284354 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | S400251735 | 01 | MA | MEDICARE PTAN | OTHER |