Provider Demographics
NPI:1962690271
Name:GERMAK, DEVON DICLERICO (ACNP-BC)
Entity type:Individual
Prefix:MS
First Name:DEVON
Middle Name:DICLERICO
Last Name:GERMAK
Suffix:
Gender:F
Credentials:ACNP-BC
Other - Prefix:MS
Other - First Name:DEVON
Other - Middle Name:THOMSON
Other - Last Name:DICLERICO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ACNP-BC
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 LAKE AVENUE NORTH
Practice Address - Street 2:DEPARTMENT OF SURGERY
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-856-5599
Practice Address - Fax:508-856-8329
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RINPP37706363L00000X
MA267790363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110076991AMedicaid
MA0716081Medicaid