Provider Demographics
NPI:1033980685
Name:DUCASSE, MANISHA
Entity Type:Individual
Prefix:
First Name:MANISHA
Middle Name:
Last Name:DUCASSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 PARK ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-2667
Mailing Address - Country:US
Mailing Address - Phone:781-354-6889
Mailing Address - Fax:
Practice Address - Street 1:243 PARK ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-2667
Practice Address - Country:US
Practice Address - Phone:781-354-6889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2373418163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice