Healthcare Provider Details

I. General information

NPI: 1134232077
Provider Name (Legal Business Name): ANICIA BOUTIN YOUNG CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 03/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 ST GEORGE RD
SPRINGFIELD MA
01104
US

IV. Provider business mailing address

163 BILTON RD
SOMERS CT
06071-1067
US

V. Phone/Fax

Practice location:
  • Phone: 413-736-7463
  • Fax: 413-736-7466
Mailing address:
  • Phone: 860-306-9717
  • Fax: 860-763-4111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number049381
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN197541
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: