MEDICARE: LISA A. BOUCHER MS, APRN, BC, ANP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	206013	MA

General Provider Information

NPI Number	:	1033210182
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA A. BOUCHER MS, APRN, BC, ANP

Provider Business Mailing Address
First Line	:	110 FARM POND RD
Second Line	:
City	:	OAKHAM
State	:	MA
Zip	:	01068-9551
Country	:	US
Telephone Number	:	508-882-3722
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 SALISBURY ST
Second Line	:	ASSUMPTION COLLEGE - STUDENT HEALTH SERVICES
City	:	WORCESTER
State	:	MA
Zip	:	01609-1265
Country	:	US
Telephone Number	:	508-767-7329
Fax Number	:	508-767-7102

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	07/08/2007

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