Basic Information
| Provider Information | |||||||||
| NPI: | 1437593761 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOROHO | ||||||||
| FirstName: | STEFANIE | ||||||||
| MiddleName: | VERONICA | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN, MSN, CPNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CALDWELL | ||||||||
| OtherFirstName: | STEFANIE | ||||||||
| OtherMiddleName: | VERONICA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN, MSN, CPNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 300 LONGWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021155724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173550610 | ||||||||
| FaxNumber: | 6177341034 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 LONGWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021155724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173550610 | ||||||||
| FaxNumber: | 6177341034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2013 | ||||||||
| LastUpdateDate: | 03/08/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | RN281364 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 110123790A | 05 | MA | MEDICAID |