Provider Demographics
NPI:1932178167
Name:COUTU, WENDY J (NP)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:J
Last Name:COUTU
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440-1336
Mailing Address - Country:US
Mailing Address - Phone:978-632-3420
Mailing Address - Fax:
Practice Address - Street 1:242 GREEN ST
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440-1336
Practice Address - Country:US
Practice Address - Phone:978-632-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA218088363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAA43377OtherHARVARD PILGRIM
MA0704041Medicaid
MANP5127OtherBLUE CROSS
MANP5127Medicare ID - Type Unspecified
MAQ51988Medicare UPIN
MAAA43377OtherHARVARD PILGRIM