Healthcare Provider Details

I. General information

NPI: 1386720175
Provider Name (Legal Business Name): MICHELE JACQUELINE BORISUK RN, CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 07/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE FARLEY 612
BOSTON MA
02115-5724
US

IV. Provider business mailing address

300 LONGWOOD AVENUE FARLEY 612
BOSTON MA
02115
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-3515
  • Fax:
Mailing address:
  • Phone: 617-355-3515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number5003911
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberTP006200D
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN2269575
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: