Individual
NICOLE DETTMANN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
133 BROOKLINE AVE, BOSTON, MA 02215-3904
(617) 421-1000
(617) 421-6084
Mailing address
147 MILK ST, PROVIDER ENROLLMENT - 9TH FLOOR, BOSTON, MA 02109-4806
(617) 559-8053
(617) 421-3487
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
1603
MA
363AM0700X
Medical Physician Assistant
1603
MA
Other
Enumeration date
04/14/2006
Last updated
08/07/2007
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