Healthcare Provider Details

I. General information

NPI: 1649115726
Provider Name (Legal Business Name): MAKENSIE BOULGER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2026
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 EAGLE CREST DR
RANGELY CO
81648-2104
US

IV. Provider business mailing address

95 COUNTY ROAD 101
RANGELY CO
81648-2011
US

V. Phone/Fax

Practice location:
  • Phone: 970-675-5011
  • Fax:
Mailing address:
  • Phone: 435-340-0857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1644596
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: