Healthcare Provider Details

I. General information

NPI: 1548365984
Provider Name (Legal Business Name): PAMELA MARIE GOUDREAU CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PAMELA MARIE BOULEY CRNA

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 01/30/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVH 59 PAGE HILL RD
BERLIN NH
03570
US

IV. Provider business mailing address

59 PAGE HILL RD
BERLIN NH
03570
US

V. Phone/Fax

Practice location:
  • Phone: 603-752-2200
  • Fax: 843-777-8705
Mailing address:
  • Phone: 603-752-2200
  • Fax: 843-777-8705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPN 3035
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number034214-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: