Provider Demographics
NPI:1386720175
Name:BORISUK, MICHELE JACQUELINE (RN, CPNP)
Entity type:Individual
Prefix:MISS
First Name:MICHELE
Middle Name:JACQUELINE
Last Name:BORISUK
Suffix:
Gender:F
Credentials:RN, CPNP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:300 LONGWOOD AVENUE
Mailing Address - Street 2:FARLEY 612
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115
Mailing Address - Country:US
Mailing Address - Phone:617-355-3515
Mailing Address - Fax:
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:FARLEY 612
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-3515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5003911363LP0222X
PATP006200D363L00000X
MARN2269575363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNP1261Medicaid
NC2593303Medicare PIN