Provider Demographics
NPI:1861725715
Name:BOULOGNE, PATRICIA
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:BOULOGNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 QUINCY SHORE DR APT 29
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02171-2930
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:148 QUINCY SHORE DR APT 29
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02171-2930
Practice Address - Country:US
Practice Address - Phone:617-901-0925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-10
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171100000X
MA935111NS0005X, 111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
No171100000XOther Service ProvidersAcupuncturist
No111NS0005XChiropractic ProvidersChiropractorSports Physician