Healthcare Provider Details

I. General information

NPI: 1326660176
Provider Name (Legal Business Name): LINDSAY BOUCHARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2020
Last Update Date: 12/29/2020
Certification Date: 12/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-5092
US

IV. Provider business mailing address

PO BOX 100277
GAINESVILLE FL
32610-0277
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-8352
  • Fax:
Mailing address:
  • Phone: 352-273-9804
  • Fax: 352-392-6481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9113469
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: