Healthcare Provider Details

I. General information

NPI: 1013960699
Provider Name (Legal Business Name): LISA DUMOUCHEL APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 05/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BROOKLINE AVE FA 813
BOSTON MA
02215-5400
US

IV. Provider business mailing address

330 BROOKLINE AVE FA 813
BOSTON MA
02215-5400
US

V. Phone/Fax

Practice location:
  • Phone: 617-632-9880
  • Fax: 617-632-9890
Mailing address:
  • Phone: 617-632-9880
  • Fax: 617-632-9890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number203471
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: