Healthcare Provider Details

I. General information

NPI: 1720323843
Provider Name (Legal Business Name): ROSEMARY BOUDREAUX
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ROSEMARY ATKINSON BOUDREAUX RN, IBCLC

II. Dates (important events)

Enumeration Date: 11/29/2012
Last Update Date: 11/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9549 E 57TH TER
RAYTOWN MO
64133-3395
US

IV. Provider business mailing address

9549 E 57TH TER
RAYTOWN MO
64133-3395
US

V. Phone/Fax

Practice location:
  • Phone: 816-678-7825
  • Fax: 816-353-2617
Mailing address:
  • Phone: 816-678-7825
  • Fax: 816-353-2617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number163WL0100X
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: