=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174469902
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. CANDICE JEAN BOUCHE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2026
-----------------------------------------------------
Last Update Date | 04/24/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 380 48TH AVE SW
-----------------------------------------------------
City | BISMARK
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-934-5967
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 380 48TH AVE SW
-----------------------------------------------------
City | BISMARK
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-934-5967
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3747P1801X
-----------------------------------------------------
Taxonomy Name | Personal Care Attendant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------