Provider Demographics
NPI:1003237744
Name:DEFUSCO, COURTNEY WILSON (NP)
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:WILSON
Last Name:DEFUSCO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:ANNE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:55 FRUIT ST
Mailing Address - Street 2:BIGELOW 800
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:BIGELOW 800
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-726-2256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-24
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN281678363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health