Healthcare Provider Details

I. General information

NPI: 1154027761
Provider Name (Legal Business Name): MRS. MELISSA A JOHNSON BOUCHER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 02/06/2023
Certification Date: 02/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 ARDMORE ST
SAINT AUGUSTINE FL
32092-3441
US

IV. Provider business mailing address

1245 ARDMORE ST
SAINT AUGUSTINE FL
32092-3441
US

V. Phone/Fax

Practice location:
  • Phone: 631-374-9793
  • Fax:
Mailing address:
  • Phone: 631-374-9793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: