Provider Demographics
NPI:1144897448
Name:MACDONALD, SOPHIE (NP)
Entity type:Individual
Prefix:
First Name:SOPHIE
Middle Name:
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 HILLSIDE ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-5219
Mailing Address - Country:US
Mailing Address - Phone:617-549-7836
Mailing Address - Fax:
Practice Address - Street 1:695 TRUMAN HWY STE 203
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:MA
Practice Address - Zip Code:02136-3552
Practice Address - Country:US
Practice Address - Phone:617-361-1470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2301196363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics