Basic Information
| Provider Information | |||||||||
| NPI: | 1447741293 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DELISLE | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | C-NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 OLD CANAL DR | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018512730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9784536800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 22 OLD CANAL DR | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018512730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9784536800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2018 | ||||||||
| LastUpdateDate: | 09/27/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | RN2322923 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.