Provider Demographics
NPI:1962009852
Name:EYSSALLENNE, GERARD PHILIP
Entity type:Individual
Prefix:
First Name:GERARD
Middle Name:PHILIP
Last Name:EYSSALLENNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 211
Mailing Address - Street 2:
Mailing Address - City:METHUEN
Mailing Address - State:MA
Mailing Address - Zip Code:01844-0211
Mailing Address - Country:US
Mailing Address - Phone:978-943-1049
Mailing Address - Fax:
Practice Address - Street 1:34 HAVERHILL STREET
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01841
Practice Address - Country:US
Practice Address - Phone:978-686-0090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN234932163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse