MEDICARE: MRS. HEIDI ANGELA BOUVETTE LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse		WI

General Provider Information

NPI Number	:	1023077195
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. HEIDI ANGELA BOUVETTE LPN

Provider Business Mailing Address
First Line	:	1306 SUN TERRACE ST
Second Line	:
City	:	LUXEMBURG
State	:	WI
Zip	:	54217-1339
Country	:	US
Telephone Number	:	920-845-1777
Fax Number	:

Provider Business Practice Location Address
First Line	:	1306 SUN TERRACE ST
Second Line	:
City	:	LUXEMBURG
State	:	WI
Zip	:	54217-1339
Country	:	US
Telephone Number	:	920-845-1777
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/18/2006
Last Update Date	:	07/08/2007

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