Provider Demographics
NPI:1871544981
Name:BOURQUE, ANNE MARIE (NP)
Entity type:Individual
Prefix:
First Name:ANNE MARIE
Middle Name:
Last Name:BOURQUE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:950 WINTER ST
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1424
Mailing Address - Country:US
Mailing Address - Phone:781-419-8354
Mailing Address - Fax:781-419-8479
Practice Address - Street 1:950 WINTER ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1424
Practice Address - Country:US
Practice Address - Phone:781-419-8354
Practice Address - Fax:781-419-8479
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA132090363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0706779Medicaid
MA0706779Medicaid
MA0706779Medicaid