Healthcare Provider Details

I. General information

NPI: 1033157227
Provider Name (Legal Business Name): NAN M BOUCHER ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 11/08/2022
Certification Date: 11/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 CAMPUS AVE SUITE 201
LEWISTON ME
04240-6045
US

IV. Provider business mailing address

PO BOX 95000 LBX 7650
PHILADELPHIA PA
19195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 207-777-8810
  • Fax: 207-777-8155
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP081044
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberCNP81044
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: