Healthcare Provider Details

I. General information

NPI: 1285049759
Provider Name (Legal Business Name): MS. CHRISTINE BOUTTE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 06/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2804 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70506-5906
US

IV. Provider business mailing address

2804 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70506-5906
US

V. Phone/Fax

Practice location:
  • Phone: 337-981-5156
  • Fax: 337-981-0673
Mailing address:
  • Phone: 337-981-5156
  • Fax: 337-981-0673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number101637-7753
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: