Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP2300X | Nurse Practitioner - Primary Care | 114361 | MA |
NPI | 1023030145 |
---|---|
Provider Name | Bernice A Ezell |
First Address | Springfield, MA 01199-1000 |
Second Address | Springfield, MA 01199-0001 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
S76856 | (02) | MA |