Basic Information
| Provider Information | |||||||||
| NPI: | 1043572472 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUTIN | ||||||||
| FirstName: | MARIE | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 280 CHESTNUT ST | ||||||||
| Address2: | 2ND FL | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011991619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137945700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 759 CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011991619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137943233 | ||||||||
| FaxNumber: | 4137949060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2012 | ||||||||
| LastUpdateDate: | 04/23/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 229951 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LA2100X | 229951 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.