Provider Demographics
NPI:1619473733
Name:LOUIS-JEAN, NICOLE ANNA (DO)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANNA
Last Name:LOUIS-JEAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:BUTUZOV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 24532
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-4532
Mailing Address - Country:US
Mailing Address - Phone:781-744-8771
Mailing Address - Fax:
Practice Address - Street 1:36 ESSEX RD STE 1
Practice Address - Street 2:
Practice Address - City:IPSWICH
Practice Address - State:MA
Practice Address - Zip Code:01938-2609
Practice Address - Country:US
Practice Address - Phone:978-356-5522
Practice Address - Fax:978-356-0218
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2025-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311861207Q00000X
MA295367207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program