1861790479 NPI number — MS. LAURA SUSANNAH TANNENBAUM NNP

Table of content: MS. LAURA SUSANNAH TANNENBAUM NNP (NPI 1861790479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861790479 NPI number — MS. LAURA SUSANNAH TANNENBAUM NNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TANNENBAUM
Provider First Name:
LAURA
Provider Middle Name:
SUSANNAH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
NNP
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:
1861790479
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 LONGWOOD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02115-5724
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-355-8076
Provider Business Mailing Address Fax Number:
617-730-0902

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 DOW AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02476-7142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-643-0804
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/05/2011

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: 363LN0000X , with the licence number:  236051 , 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)





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