Healthcare Provider Details

I. General information

NPI: 1336575471
Provider Name (Legal Business Name): CAROL E. BOETTCHER ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2013
Last Update Date: 12/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8491 S US HIGHWAY 1
PORT ST LUCIE FL
34952-3360
US

IV. Provider business mailing address

8491 S US HIGHWAY 1
PORT ST LUCIE FL
34952-3360
US

V. Phone/Fax

Practice location:
  • Phone: 772-446-4883
  • Fax: 772-446-4875
Mailing address:
  • Phone: 772-446-4883
  • Fax: 772-446-4875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0000X
TaxonomyPain Management Registered Nurse
License NumberARNP2844672
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP2844672
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: