Provider Demographics
NPI:1013960699
Name:DUMOUCHEL, LISA (APRN)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:DUMOUCHEL
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 1:330 BROOKLINE AVE
Mailing Address - Street 2:FA 813
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5400
Mailing Address - Country:US
Mailing Address - Phone:617-632-9880
Mailing Address - Fax:617-632-9890
Practice Address - Street 1:330 BROOKLINE AVE
Practice Address - Street 2:FA 813
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5400
Practice Address - Country:US
Practice Address - Phone:617-632-9880
Practice Address - Fax:617-632-9890
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2014-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA203471363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP5150OtherBLUE CROSS BLUE SHIELD
MA0706973Medicaid
MA0706973Medicaid