Healthcare Provider Details

I. General information

NPI: 1609062793
Provider Name (Legal Business Name): MICHELE A BOUTILIER LHIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2007
Last Update Date: 02/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 N. CROATOAN HWY SUITE G
KILL DEVIL HILLS NC
27948
US

IV. Provider business mailing address

128 ACORN LANE
POINT HARBOR NC
27964
US

V. Phone/Fax

Practice location:
  • Phone: 252-441-2595
  • Fax: 252-441-2595
Mailing address:
  • Phone: 252-441-2595
  • Fax: 252-441-2595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1003
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: