Provider Demographics
NPI:1982875902
Name:PAUL-BLANC, FABIENNE (NP)
Entity type:Individual
Prefix:
First Name:FABIENNE
Middle Name:
Last Name:PAUL-BLANC
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 HARRISON AVE
Mailing Address - Street 2:YACC BN-C7
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-4001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:725 ALBANY ST
Practice Address - Street 2:SHAPIRO LOWER LEVEL
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2526
Practice Address - Country:US
Practice Address - Phone:617-638-6287
Practice Address - Fax:617-638-6284
Is Sole Proprietor?:No
Enumeration Date:2008-03-18
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA269503363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110079011AMedicaid