Healthcare Provider Details

I. General information

NPI: 1568488419
Provider Name (Legal Business Name): NAN J BOUCHER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 11/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 MARQUIS RD
FREEPORT ME
04032-6477
US

IV. Provider business mailing address

39 WALLACE AVE
SO PORTLAND ME
04106-6143
US

V. Phone/Fax

Practice location:
  • Phone: 207-865-6131
  • Fax: 207-865-9399
Mailing address:
  • Phone: 207-761-0650
  • Fax: 207-761-8198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR028338
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: