Healthcare Provider Details

I. General information

NPI: 1437617719
Provider Name (Legal Business Name): LISA DANIELE BOUILLION AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2019
Last Update Date: 03/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7201 MANCHACA RD
AUSTIN TX
78745-5283
US

IV. Provider business mailing address

7201 MANCHACA RD STE B
AUSTIN TX
78745-5284
US

V. Phone/Fax

Practice location:
  • Phone: 512-443-3577
  • Fax: 512-445-6027
Mailing address:
  • Phone: 512-443-3577
  • Fax: 512-445-6027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP1407100
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: