Provider Demographics
NPI:1639887060
Name:BAZARIAN, NICOLE ANN
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANN
Last Name:BAZARIAN
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 1:13 GREENMEADOW DR
Mailing Address - Street 2:
Mailing Address - City:N BILLERICA
Mailing Address - State:MA
Mailing Address - Zip Code:01862-1921
Mailing Address - Country:US
Mailing Address - Phone:781-439-0389
Mailing Address - Fax:
Practice Address - Street 1:92 MONTVALE AVE
Practice Address - Street 2:
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-3647
Practice Address - Country:US
Practice Address - Phone:781-451-0072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-15
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2327337363LP0200X, 163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics