Healthcare Provider Details

I. General information

NPI: 1063414092
Provider Name (Legal Business Name): GENEI S BOUGHER ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 GULF BREEZE PKWY SUITE 300
GULF BREEZE FL
32561-4495
US

IV. Provider business mailing address

400 GULF BREEZE PKWY SUITE 300
GULF BREEZE FL
32561-4495
US

V. Phone/Fax

Practice location:
  • Phone: 850-932-5055
  • Fax: 850-932-1404
Mailing address:
  • Phone: 850-932-5055
  • Fax: 850-932-1404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN 2565762
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: