Basic Information
| Provider Information | |||||||||
| NPI: | 1801365663 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOULET | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | BRISSETTE | ||||||||
| OtherFirstName: | CHRISTINA | ||||||||
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| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 299 CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | PASCOAG | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028592606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4019526613 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 411 CHANDLER ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016023339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135842173 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2018 | ||||||||
| LastUpdateDate: | 11/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN2262724 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.