Healthcare Provider Details

I. General information

NPI: 1073031548
Provider Name (Legal Business Name): HEATHER R BOUCHER LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 FREEDOM DR
NAPOLEON OH
43545-9038
US

IV. Provider business mailing address

507 W MORENCI ST APT A
LYONS OH
43533-9651
US

V. Phone/Fax

Practice location:
  • Phone: 419-599-1660
  • Fax: 419-592-8336
Mailing address:
  • Phone: 419-250-0794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN.143581.MEDS-IV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: