Healthcare Provider Details

I. General information

NPI: 1053713032
Provider Name (Legal Business Name): LEIGH BASTABLE POITEVENT FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2014
Last Update Date: 09/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 WHITE ST STE 1
CAMBRIDGE MA
02140-1449
US

IV. Provider business mailing address

250 1ST AVE UNIT 508
CHARLESTOWN MA
02129-4401
US

V. Phone/Fax

Practice location:
  • Phone: 617-876-5519
  • Fax:
Mailing address:
  • Phone: 315-345-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2246591
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: