MEDICARE: LAWNA BLACKWOOD WIGLE FNP

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	363LF0000X	Family Nurse Practitioner	2268300	MA

General Provider Information

NPI Number	:	1205116225
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAWNA BLACKWOOD WIGLE FNP

Provider Business Mailing Address
First Line	:	2014 WASHINGTON ST FL 3
Second Line	:
City	:	NEWTON LOWER FALLS
State	:	MA
Zip	:	02462-1607
Country	:	US
Telephone Number	:	617-243-6144
Fax Number	:	617-243-5684

Provider Business Practice Location Address
First Line	:	2014 WASHINGTON ST FL 3
Second Line	:
City	:	NEWTON LOWER FALLS
State	:	MA
Zip	:	02462-1607
Country	:	US
Telephone Number	:	617-243-6144
Fax Number	:	617-243-5684

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

Provider Enumeration Date	:	08/22/2011
Last Update Date	:	02/04/2019

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