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Individual

DIANE BOURQUE

Active
Sole proprietor
No

Provider details

NPI number
Gender
F
Credential
NP

Contact information

Practice address
133 BROOKLINE AVE, ADULT TELECOM, BOSTON, MA 02215-3904
(617) 421-1000
Mailing address
147 MILK ST FL 9, PROVIDER ENROLLMENT, BOSTON, MA 02109-4806
(617) 559-8374
(617) 421-3487

Taxonomy

Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
124668
MA

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
0367524
MA
Enumeration date
08/04/2008
Last updated
08/04/2008
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