Healthcare Provider Details

I. General information

NPI: 1205815230
Provider Name (Legal Business Name): KAREN E BOULLAIN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 01/27/2020
Certification Date: 01/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 DELK RD SE SUITE 700 #166
MARIETTA GA
30067-5320
US

IV. Provider business mailing address

2900 DELK RD SE SUITE 700 PMB 166
MARIETTA GA
30067-5320
US

V. Phone/Fax

Practice location:
  • Phone: 678-640-7536
  • Fax:
Mailing address:
  • Phone: 678-640-7536
  • Fax: 770-492-2935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN063260
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: