=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023966934
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARISSA PROVENCHER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2026
-----------------------------------------------------
Last Update Date | 03/17/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 930 COMMONWEALTH AVE
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02215-1274
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-414-6800
-----------------------------------------------------
Fax | 617-414-6800
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 ARBROTH ST
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02122-2511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-401-2389
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WP2201X
-----------------------------------------------------
Taxonomy Name | Ambulatory Care Registered Nurse
-----------------------------------------------------
License Number | RN2343674
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------