Healthcare Provider Details

I. General information

NPI: 1265166979
Provider Name (Legal Business Name): JUSTINE DESLAURIERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2022
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 RAILROAD AVE
SOUTH HAMILTON MA
01982-2218
US

IV. Provider business mailing address

41 MALL RD
BURLINGTON MA
01805-0002
US

V. Phone/Fax

Practice location:
  • Phone: 978-468-7381
  • Fax:
Mailing address:
  • Phone: 978-744-8085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2340030
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN2340030
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: