Healthcare Provider Details

I. General information

NPI: 1760631923
Provider Name (Legal Business Name): BRENDA VIGUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2008
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 CHURCH ST
LOWELL MA
01852-6113
US

IV. Provider business mailing address

58 JERSEY ST
DEDHAM MA
02026-4915
US

V. Phone/Fax

Practice location:
  • Phone: 978-674-6744
  • Fax:
Mailing address:
  • Phone: 617-640-3857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number194285
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP8053
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number194285
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: