1831204932 NPI number — DR. ELLEN D NANNIS PH.D.

Table of content: DR. ELLEN D NANNIS PH.D. (NPI 1831204932)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831204932 NPI number — DR. ELLEN D NANNIS PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NANNIS
Provider First Name:
ELLEN
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831204932
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
38 LINCOLN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02421-6824
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-861-1818
Provider Business Mailing Address Fax Number:
781-861-2057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
57 BEDFORD ST
Provider Second Line Business Practice Location Address:
SUITE 125
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02420-4500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-861-1818
Provider Business Practice Location Address Fax Number:
781-861-2057
Provider Enumeration Date:
08/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  6950 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11434 . This is a "OPTIONS PROVIDER NUMBER" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: W05477 . This is a "BLUE CROSS PROVIDER NUMBE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 755578 . This is a "TUFTS PROVIDER NUMBER" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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