Healthcare Provider Details

I. General information

NPI: 1619302239
Provider Name (Legal Business Name): SARAH JANE BOUC NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2013
Last Update Date: 11/24/2021
Certification Date: 11/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3509 DEWEY ST
MANITOWOC WI
54220-5813
US

IV. Provider business mailing address

3301 W FOREST HOME AVE
MILWAUKEE WI
53215-2843
US

V. Phone/Fax

Practice location:
  • Phone: 920-686-5732
  • Fax: 920-686-5726
Mailing address:
  • Phone: 414-389-2377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number9680-033
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number19724330
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: