Provider Demographics
NPI:1083489876
Name:LEVINE, LIBBY ROSE (FNP)
Entity type:Individual
Prefix:
First Name:LIBBY
Middle Name:ROSE
Last Name:LEVINE
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Gender:
Credentials:FNP
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Mailing Address - Street 1:960 MASSACHUSETTS AVENUE
Mailing Address - Street 2:FL 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 NEVINS ST
Practice Address - Street 2:SUITE 306
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-3514
Practice Address - Country:US
Practice Address - Phone:617-789-2045
Practice Address - Fax:617-789-2045
Is Sole Proprietor?:No
Enumeration Date:2023-11-21
Last Update Date:2025-03-12
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Provider Licenses
StateLicense IDTaxonomies
MARN2279436363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110207123AMedicaid