Provider Demographics
NPI:1164005302
Name:BOLDUC, MICHELLE (FNP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BOLDUC
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 SHATTUCK WAY
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:NH
Mailing Address - Zip Code:03801-7876
Mailing Address - Country:US
Mailing Address - Phone:603-433-8488
Mailing Address - Fax:603-373-6009
Practice Address - Street 1:278 LAFAYETTE RD STE E5
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-5455
Practice Address - Country:US
Practice Address - Phone:603-433-8488
Practice Address - Fax:603-373-6009
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHF02210730207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty