Provider Demographics
NPI:1265166979
Name:DESLAURIERS, JUSTINE
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:DESLAURIERS
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 1:41 MALL RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0002
Mailing Address - Country:US
Mailing Address - Phone:978-744-8085
Mailing Address - Fax:
Practice Address - Street 1:15 RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HAMILTON
Practice Address - State:MA
Practice Address - Zip Code:01982-2218
Practice Address - Country:US
Practice Address - Phone:978-468-7381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-11
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2340030163W00000X
MARN2340030363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse