Healthcare Provider Details

I. General information

NPI: 1457269995
Provider Name (Legal Business Name): TERESA LYNN BOUDREAUX RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30576 STATE HIGHWAY 18
LUCERNE VALLEY CA
92356-9290
US

IV. Provider business mailing address

30576 STATE HIGHWAY 18
LUCERNE VALLEY CA
92356-9290
US

V. Phone/Fax

Practice location:
  • Phone: 909-202-7382
  • Fax:
Mailing address:
  • Phone: 909-202-7382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number728841
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: