Provider Demographics
NPI:1114114410
Name:NUTTER, LISA (RN/PC)
Entity Type:Individual
Prefix:MISS
First Name:LISA
Middle Name:
Last Name:NUTTER
Suffix:
Gender:F
Credentials:RN/PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 PHOEBE AVE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01854-2409
Mailing Address - Country:US
Mailing Address - Phone:978-459-8836
Mailing Address - Fax:
Practice Address - Street 1:12 ALFRED ST
Practice Address - Street 2:SUITE 200
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-1972
Practice Address - Country:US
Practice Address - Phone:781-646-0500
Practice Address - Fax:781-646-7130
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA229836364SP0808X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1305638Medicaid