Basic Information
Provider Information | |||||||||
NPI: | 1225008592 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DESROCHERS | ||||||||
FirstName: | MARIAN | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GAMACHE | ||||||||
OtherFirstName: | MARIAN | ||||||||
OtherMiddleName: | J | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | A.R.N.P. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 13 HIGHFIELD DR | ||||||||
Address2: |   | ||||||||
City: | ALLENSTOWN | ||||||||
State: | NH | ||||||||
PostalCode: | 032752622 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6032680332 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 246 WALNUT ST | ||||||||
Address2: |   | ||||||||
City: | NEWTON | ||||||||
State: | MA | ||||||||
PostalCode: | 024601639 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6172443322 | ||||||||
FaxNumber: | 6172441827 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/26/2006 | ||||||||
LastUpdateDate: | 02/11/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 046248-23 | NH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 30342403 | 05 | NH |   | MEDICAID |