=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457269995
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERESA LYNN BOUDREAUX RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2026
-----------------------------------------------------
Last Update Date | 08/27/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30576 STATE HIGHWAY 18
-----------------------------------------------------
City | LUCERNE VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92356-9290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-202-7382
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30576 STATE HIGHWAY 18
-----------------------------------------------------
City | LUCERNE VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92356-9290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-202-7382
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WH0200X
-----------------------------------------------------
Taxonomy Name | Home Health Registered Nurse
-----------------------------------------------------
License Number | 728841
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------