Provider Demographics
NPI:1215628664
Name:OSTERHOUDT, STACY JILL (ACNPC-AG,)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:JILL
Last Name:OSTERHOUDT
Suffix:
Gender:F
Credentials:ACNPC-AG,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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 1:725 ALBANY STREET, SUITE 7B
Practice Address - Street 2:SHAPIRO BLDG.
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-638-8456
Practice Address - Fax:617-638-8465
Is Sole Proprietor?:No
Enumeration Date:2023-05-17
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2389809363LA2100X, 363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110204587AMedicaid
NH3143868Medicaid