Basic Information
| Provider Information | |||||||||
| NPI: | 1295779890 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COSTANTINO | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 AMBER WAY | ||||||||
| Address2: | |||||||||
| City: | GROVELAND | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018342108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9783770592 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 LONGWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021155724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173556000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 06/15/2008 | ||||||||
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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 | 211483 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.