Provider Demographics
NPI:1215090170
Name:BOISSEAU, JOHN L (RN)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:BOISSEAU
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 BLACKSTONE ST
Mailing Address - Street 2:
Mailing Address - City:BLACKSTONE
Mailing Address - State:MA
Mailing Address - Zip Code:01504-1312
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:190 LENOX ST
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-3416
Practice Address - Country:US
Practice Address - Phone:781-769-8670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA225680363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIJB62852Medicaid