Provider Demographics
NPI:1063177004
Name:BOUTIN, NANCY E (PMHNP)
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:E
Last Name:BOUTIN
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01854-2442
Mailing Address - Country:US
Mailing Address - Phone:978-502-1302
Mailing Address - Fax:
Practice Address - Street 1:12 ALFRED ST STE 200
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-1915
Practice Address - Country:US
Practice Address - Phone:781-646-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-04
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2277518163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse