Healthcare Provider Details

I. General information

NPI: 1962705236
Provider Name (Legal Business Name): CAROL DIANE MITCHELL-BOUDREAU FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2010
Last Update Date: 04/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 TURNPIKE ROAD
SOUTHBOROUGH MA
01772-2108
US

IV. Provider business mailing address

33 TURNPIKE ROAD
SOUTHBOROUGH MA
01772-2108
US

V. Phone/Fax

Practice location:
  • Phone: 508-481-1015
  • Fax: 508-303-8542
Mailing address:
  • Phone: 508-481-1015
  • Fax: 508-303-8542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number173636
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: