Healthcare Provider Details

I. General information

NPI: 1407641137
Provider Name (Legal Business Name): GENEVIEVE JOSEE BOUDREAU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2025
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 S 17TH ST
WILMINGTON NC
28401-7407
US

IV. Provider business mailing address

PO BOX 936857
ATLANTA GA
31193-6857
US

V. Phone/Fax

Practice location:
  • Phone: 910-343-7000
  • Fax: 910-667-5650
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRTL26-0888
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number101517851
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: