Provider Demographics
NPI:1144343997
Name:MOYNIHAN, JACQUELYN MARIE (RN)
Entity type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:MARIE
Last Name:MOYNIHAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 RUST ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAMILTON
Mailing Address - State:MA
Mailing Address - Zip Code:01982-2222
Mailing Address - Country:US
Mailing Address - Phone:978-468-3622
Mailing Address - Fax:781-944-9808
Practice Address - Street 1:33 MACARTHUR RD
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-1629
Practice Address - Country:US
Practice Address - Phone:978-921-0745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA215615163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0704814Medicaid