Basic Information
| Provider Information | |||||||||
| NPI: | 1922764810 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRODY | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | |||||||||
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| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAMILTON | ||||||||
| OtherFirstName: | DIANA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 207 HARVARD ST # 2 | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021392736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062955814 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 55 FRUIT ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021142621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177262000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2021 | ||||||||
| LastUpdateDate: | 11/15/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN2355498 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.