Provider Demographics
NPI:1972974277
Name:ILLSLEY, ALLISON MARIE (NP)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:MARIE
Last Name:ILLSLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ALLSON
Other - Middle Name:
Other - Last Name:RUMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
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:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:774-443-7552
Practice Address - Fax:774-441-6086
Is Sole Proprietor?:No
Enumeration Date:2015-10-13
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2281827363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110108544AMedicaid
MAS400285737Medicare PIN