Provider Demographics
NPI:1649884289
Name:DEUKMEJIAN, MIRIAM
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:DEUKMEJIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIRIAM
Other - Middle Name:ANNE
Other - Last Name:LAUTENSCHLAGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10 UNDINE AVE
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:MA
Mailing Address - Zip Code:02152-1431
Mailing Address - Country:US
Mailing Address - Phone:203-583-6031
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-820-8065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2308486163W00000X
MARN2308486363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse