=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053541326
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERESA FAYE BOUDRIE RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2009
-----------------------------------------------------
Last Update Date | 07/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 650 JOEL DR
-----------------------------------------------------
City | FORT CAMPBELL
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42223-5318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-798-8500
-----------------------------------------------------
Fax | 270-798-8666
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9215 ELKHORN RD
-----------------------------------------------------
City | SPRINGVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38256-4962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-336-2598
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WE0003X
-----------------------------------------------------
Taxonomy Name | Emergency Registered Nurse
-----------------------------------------------------
License Number | 130082
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------