Basic Information
| Provider Information | |||||||||
| NPI: | 1467447482 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | DEFOREST | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 WARREN ST | ||||||||
| Address2: | ROOM 339 | ||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021353601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175625359 | ||||||||
| FaxNumber: | 6175625415 | ||||||||
| Practice Location | |||||||||
| Address1: | 24 COMMON STREET, | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | WRENTHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083842223 | ||||||||
| FaxNumber: | 5083840066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2005 | ||||||||
| LastUpdateDate: | 12/01/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 107372 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0319040 | 05 | MA | MEDICAID |