Provider Demographics
NPI:1053913640
Name:PERKINS, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:PERKINS
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:LAHEY PROVIDER ENROLLMENT DEPARTMENT 41 MALL ROAD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-744-8085
Mailing Address - Fax:
Practice Address - Street 1:311 NEWBURY ST
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-1027
Practice Address - Country:US
Practice Address - Phone:978-777-5504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2259884363LF0000X
MARN2259884363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily