Provider Demographics
NPI:1689712911
Name:FORMANEK, JUDITH LOUISE (NP)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:LOUISE
Last Name:FORMANEK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 PINE RD
Mailing Address - Street 2:
Mailing Address - City:WESTFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01886-1421
Mailing Address - Country:US
Mailing Address - Phone:978-692-0994
Mailing Address - Fax:978-681-5387
Practice Address - Street 1:101 AMESBURY ST
Practice Address - Street 2:SUITE 202
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840-1323
Practice Address - Country:US
Practice Address - Phone:978-681-5258
Practice Address - Fax:978-681-5387
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA186429363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP 3248OtherBCBS
MANP 3248OtherBCBS