Healthcare Provider Details

I. General information

NPI: 1619473733
Provider Name (Legal Business Name): NICOLE ANNA LOUIS-JEAN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE BUTUZOV

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 ESSEX RD STE 1
IPSWICH MA
01938-2609
US

IV. Provider business mailing address

PO BOX 24532
NEW YORK NY
10087-4532
US

V. Phone/Fax

Practice location:
  • Phone: 978-356-5522
  • Fax: 978-356-0218
Mailing address:
  • Phone: 781-744-8771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number311861
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number295367
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: