Provider Demographics
NPI:1407837230
Name:BARTLETT-JACQUES, LARAH (NP)
Entity Type:Individual
Prefix:MRS
First Name:LARAH
Middle Name:
Last Name:BARTLETT-JACQUES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:LARAH
Other - Middle Name:
Other - Last Name:BARTLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:92 MONTVALE AVE
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-3647
Mailing Address - Country:US
Mailing Address - Phone:781-279-7040
Mailing Address - Fax:781-279-8430
Practice Address - Street 1:92 MONTVALE AVE
Practice Address - Street 2:SUITE 1400
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-3647
Practice Address - Country:US
Practice Address - Phone:781-279-7040
Practice Address - Fax:781-279-8430
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA211905363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
P37115Medicare UPIN
MANP3315Medicare ID - Type Unspecified