1689712911 NPI number — MS. JUDITH LOUISE FORMANEK NP

Table of content: MS. JUDITH LOUISE FORMANEK NP (NPI 1689712911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689712911 NPI number — MS. JUDITH LOUISE FORMANEK NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORMANEK
Provider First Name:
JUDITH
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689712911
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33 PINE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTFORD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01886-1421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-692-0994
Provider Business Mailing Address Fax Number:
978-681-5387

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 AMESBURY ST
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
LAWRENCE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01840-1323
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-681-5258
Provider Business Practice Location Address Fax Number:
978-681-5387
Provider Enumeration Date:
02/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LW0102X , with the licence number:  186429 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NP 3248 . This is a "BCBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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