Healthcare Provider Details

I. General information

NPI: 1689700635
Provider Name (Legal Business Name): LORI LYNN BOUCARD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 MULHOLLAND ST
BAY CITY MI
48708-7693
US

IV. Provider business mailing address

457 E CABIN LAKE RD
WEST BRANCH MI
48661-9787
US

V. Phone/Fax

Practice location:
  • Phone: 989-895-2324
  • Fax:
Mailing address:
  • Phone: 989-362-8636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number4704197727
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: