Provider Demographics
NPI:1871910364
Name:BOULEY, MICHELLE J (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:J
Last Name:BOULEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:J
Other - Last Name:GRAVALLESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 ORTHOPEDICS DR
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-1668
Mailing Address - Country:US
Mailing Address - Phone:978-818-6350
Mailing Address - Fax:978-854-4811
Practice Address - Street 1:1 ORTHOPEDICS DR
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-1668
Practice Address - Country:US
Practice Address - Phone:978-818-6350
Practice Address - Fax:978-854-4811
Is Sole Proprietor?:No
Enumeration Date:2014-03-24
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA4987363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical