=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689712911
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUDITH LOUISE FORMANEK NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 AMESBURY ST SUITE 202
-----------------------------------------------------
City | LAWRENCE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01840-1323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-681-5258
-----------------------------------------------------
Fax | 978-681-5387
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33 PINE RD
-----------------------------------------------------
City | WESTFORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01886-1421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-692-0994
-----------------------------------------------------
Fax | 978-681-5387
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LW0102X
-----------------------------------------------------
Taxonomy Name | Women's Health Nurse Practitioner
-----------------------------------------------------
License Number | 186429
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------