Healthcare Provider Details

I. General information

NPI: 1124531868
Provider Name (Legal Business Name): LAURETTE MANGAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2017
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 FORSYTH ST
BOSTON MA
02115-5026
US

IV. Provider business mailing address

70 FORSYTH ST
BOSTON MA
02115-5026
US

V. Phone/Fax

Practice location:
  • Phone: 617-373-2772
  • Fax:
Mailing address:
  • Phone: 617-373-2772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN283070
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: