Provider Demographics
NPI:1548261621
Name:FUNK, JANICE (PHD)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:FUNK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 MAIN ST
Mailing Address - Street 2:PO BOX 882
Mailing Address - City:PLAISTOW
Mailing Address - State:NH
Mailing Address - Zip Code:03865-3033
Mailing Address - Country:US
Mailing Address - Phone:603-382-5400
Mailing Address - Fax:603-382-4283
Practice Address - Street 1:76 SUMMER ST
Practice Address - Street 2:
Practice Address - City:HAVERHILL
Practice Address - State:MA
Practice Address - Zip Code:01830-5814
Practice Address - Country:US
Practice Address - Phone:978-469-1438
Practice Address - Fax:978-372-0404
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-11
Provider Licenses
StateLicense IDTaxonomies
MA6540173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW05327OtherBLUE SHIELD MA
MA771888OtherTUFTS
MA0525677Medicaid
MA0525677Medicaid