Provider Demographics
NPI:1386249332
Name:DECUBELLIS, DOROTHY KAYE (FNP)
Entity type:Individual
Prefix:
First Name:DOROTHY
Middle Name:KAYE
Last Name:DECUBELLIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01745-1003
Mailing Address - Country:US
Mailing Address - Phone:617-671-8052
Mailing Address - Fax:
Practice Address - Street 1:123 SUMMER ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1216
Practice Address - Country:US
Practice Address - Phone:508-363-7449
Practice Address - Fax:508-363-7512
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2274954363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110170519AMedicaid