Provider Demographics
NPI:1013426048
Name:BOULANGER, BRIANNA (APRN)
Entity Type:Individual
Prefix:MRS
First Name:BRIANNA
Middle Name:
Last Name:BOULANGER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 MAMMOTH RD
Mailing Address - Street 2:UNIT 4
Mailing Address - City:LONDONDERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03053
Mailing Address - Country:US
Mailing Address - Phone:603-473-4451
Mailing Address - Fax:603-584-4822
Practice Address - Street 1:184 MAMMOTH RD
Practice Address - Street 2:UNIT 4
Practice Address - City:LONDONDERRY
Practice Address - State:NH
Practice Address - Zip Code:03053
Practice Address - Country:US
Practice Address - Phone:603-473-4451
Practice Address - Fax:603-584-4822
Is Sole Proprietor?:No
Enumeration Date:2017-09-21
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH074103-23363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3139067Medicaid