Provider Demographics
NPI:1083298939
Name:BOISELLE, TRACI
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:BOISELLE
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 1:136 BREWSTER RD
Mailing Address - Street 2:
Mailing Address - City:GRISWOLD
Mailing Address - State:CT
Mailing Address - Zip Code:06351-2614
Mailing Address - Country:US
Mailing Address - Phone:860-460-6473
Mailing Address - Fax:
Practice Address - Street 1:136 BREWSTER RD
Practice Address - Street 2:
Practice Address - City:GRISWOLD
Practice Address - State:CT
Practice Address - Zip Code:06351-2614
Practice Address - Country:US
Practice Address - Phone:860-460-6473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider