Provider Demographics
NPI:1871560417
Name:FERTITTA, LUISA C (OGNP)
Entity type:Individual
Prefix:MRS
First Name:LUISA
Middle Name:C
Last Name:FERTITTA
Suffix:
Gender:F
Credentials:OGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 WOODPARK CIR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-7207
Mailing Address - Country:US
Mailing Address - Phone:781-861-7613
Mailing Address - Fax:781-862-9240
Practice Address - Street 1:5 WOODPARK CIR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-7207
Practice Address - Country:US
Practice Address - Phone:781-861-7613
Practice Address - Fax:781-862-9240
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA116474363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS75975Medicare UPIN