=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437888138
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RANDI NICOLE BOUCHILLON DNP, FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2022
-----------------------------------------------------
Last Update Date | 05/15/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 85 HOSPITAL RD
-----------------------------------------------------
City | PRINCE FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20678-4018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-535-2300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23120 POND POINT FARM LN
-----------------------------------------------------
City | CHAPTICO
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20621-2424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-717-9661
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Registered Nurse
-----------------------------------------------------
License Number | R244896
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | R244896
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------