Provider Demographics
NPI:1366961310
Name:CORALLINO, CHRISTINE ANNA (AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:ANNA
Last Name:CORALLINO
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 FOSTER ST APT 3
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-5519
Mailing Address - Country:US
Mailing Address - Phone:603-867-1960
Mailing Address - Fax:
Practice Address - Street 1:14 FOSTER STREET
Practice Address - Street 2:#3
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02109
Practice Address - Country:US
Practice Address - Phone:603-867-1960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2017009488363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2017009488OtherANCC