Healthcare Provider Details

I. General information

NPI: 1881167047
Provider Name (Legal Business Name): HOLLY SUSAN BOUTWELL RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2019
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 E SOUTH BLVD
MONTGOMERY AL
36116-2409
US

IV. Provider business mailing address

1535 COUNTY ROAD 37
FITZPATRICK AL
36029-2909
US

V. Phone/Fax

Practice location:
  • Phone: 334-286-2823
  • Fax:
Mailing address:
  • Phone: 214-995-7979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number1-156485
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: