Healthcare Provider Details

I. General information

NPI: 1760935365
Provider Name (Legal Business Name): DEBRA CATHERINE BOOYSEN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2016
Last Update Date: 07/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1626 30TH AVE
FAIRBANKS AK
99701-7466
US

IV. Provider business mailing address

2575 LINDA LN
FAIRBANKS AK
99709-2406
US

V. Phone/Fax

Practice location:
  • Phone: 907-479-7701
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number112300
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: