Provider Demographics
NPI:1871697318
Name:CACCAVALE, ANN (NP)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:CACCAVALE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 FOGG RD
Mailing Address - Street 2:
Mailing Address - City:WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190-2432
Mailing Address - Country:US
Mailing Address - Phone:781-340-8321
Mailing Address - Fax:781-340-3782
Practice Address - Street 1:55 FOGG RD
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-2432
Practice Address - Country:US
Practice Address - Phone:781-340-8321
Practice Address - Fax:781-340-3782
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA172896363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAQ44318Medicare UPIN
MANP5024Medicare ID - Type Unspecified