Healthcare Provider Details

I. General information

NPI: 1861543563
Provider Name (Legal Business Name): ANN LOUISE BOUCK FNP, APRN-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 08/29/2020
Certification Date: 08/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3232 THUNDER DR
OCEANSIDE CA
92056-4447
US

IV. Provider business mailing address

677 VALE VIEW DR
VISTA CA
92081-6722
US

V. Phone/Fax

Practice location:
  • Phone: 760-721-2493
  • Fax: 760-724-2137
Mailing address:
  • Phone: 442-232-7540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP12518
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberK293431
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: