Provider Demographics
NPI:1679270417
Name:ETEDALI, MINA R (RN)
Entity type:Individual
Prefix:
First Name:MINA
Middle Name:R
Last Name:ETEDALI
Suffix:
Gender:
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-3323
Mailing Address - Country:US
Mailing Address - Phone:978-380-2432
Mailing Address - Fax:
Practice Address - Street 1:66 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-3323
Practice Address - Country:US
Practice Address - Phone:978-380-2432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2356171163WM0705X
MARN2356171207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MARN2356171OtherRN LICENSE NUMBER