Provider Demographics
NPI:1871779587
Name:GLAVINE, CARISSA (NP)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:GLAVINE
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 1:74 LOOMIS ST
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01730-2248
Mailing Address - Country:US
Mailing Address - Phone:781-674-2900
Mailing Address - Fax:
Practice Address - Street 1:74 LOOMIS ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:01730-2248
Practice Address - Country:US
Practice Address - Phone:781-674-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-11
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA232662163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics