Basic Information
| Provider Information | |||||||||
| NPI: | 1376819235 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIZON | ||||||||
| FirstName: | NATALIE | ||||||||
| MiddleName: | DIANE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DOHENY | ||||||||
| OtherFirstName: | NATALIE | ||||||||
| OtherMiddleName: | DIZON | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 415348 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022415348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002258885 | ||||||||
| FaxNumber: | 5083341977 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 LAKE AVE N | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016550002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083348515 | ||||||||
| FaxNumber: | 5083346490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2012 | ||||||||
| LastUpdateDate: | 11/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN2277680 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | SP012072 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | AP4437 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | RN2277680 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 110093091A | 05 | MA | MEDICAID |