Healthcare Provider Details

I. General information

NPI: 1003215138
Provider Name (Legal Business Name): SUSAN RAYMOND MARCOULIER AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 08/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 N MAIN ST
LEOMINSTER MA
01453-5507
US

IV. Provider business mailing address

16 COLE RD
STERLING MA
01564-2237
US

V. Phone/Fax

Practice location:
  • Phone: 978-534-8701
  • Fax:
Mailing address:
  • Phone: 978-790-4207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberRN205674
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: