Basic Information
| Provider Information | |||||||||
| NPI: | 1124422951 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAVADPOOR | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | |||||||||
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| Credential: | DNP, AGPCNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 819 WORCESTER ST | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011511045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135436820 | ||||||||
| FaxNumber: | 4135437962 | ||||||||
| Practice Location | |||||||||
| Address1: | 819 WORCESTER ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011511056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135436820 | ||||||||
| FaxNumber: | 4135437962 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2014 | ||||||||
| LastUpdateDate: | 06/21/2017 | ||||||||
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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 | 26NJ00719500 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | 2300692 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | 2300692 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | MA | MEDICAID |