Healthcare Provider Details

I. General information

NPI: 1538255880
Provider Name (Legal Business Name): MARTHA BOULTON APRN, BC, MS, MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 11/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

468 POST RD E
WESTPORT CT
06880-4441
US

IV. Provider business mailing address

468 POST RD E
WESTPORT CT
06880-4441
US

V. Phone/Fax

Practice location:
  • Phone: 203-454-0505
  • Fax: 203-454-1115
Mailing address:
  • Phone: 203-454-0505
  • Fax: 203-454-1115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number001537
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberE35094
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: