Provider Demographics
NPI:1760119226
Name:LAFONTANT, NIRVA
Entity Type:Individual
Prefix:
First Name:NIRVA
Middle Name:
Last Name:LAFONTANT
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 1:381 S ELM ST
Mailing Address - Street 2:
Mailing Address - City:W BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02379-1536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:381 S ELM ST
Practice Address - Street 2:
Practice Address - City:W BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02379-1536
Practice Address - Country:US
Practice Address - Phone:617-435-4633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-04
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA252093363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program