Healthcare Provider Details

I. General information

NPI: 1619673027
Provider Name (Legal Business Name): ELISE BOUDREAUX CAA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2023
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 CLIFTON RD NE
ATLANTA GA
30322-1060
US

IV. Provider business mailing address

1105 CLAIREMONT AVE APT P
DECATUR GA
30030-1256
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-5437
  • Fax:
Mailing address:
  • Phone: 503-939-4962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: