Provider Demographics
NPI:1801365663
Name:BOULET, CHRISTINA
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:BOULET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:
Other - Last Name:BRISSETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:309 BELMONT ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604-1059
Mailing Address - Country:US
Mailing Address - Phone:508-368-4000
Mailing Address - Fax:
Practice Address - Street 1:309 BELMONT ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-1059
Practice Address - Country:US
Practice Address - Phone:508-368-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-21
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2262724363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily