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General NPI Number Information
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NPI Number | 1568096279
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Entity Type | Individual
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Provider Name | TRACI C BOULLION AGNP-C
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Gender | Female
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Dates
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Enumeration Date | 03/03/2020
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Last Update Date | 11/14/2024
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Provider Practice Location Address
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Address Line | 311 N CLYDE MORRIS BLVD
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City | DAYTONA BEACH
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State | FL
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Zip | 32114-2781
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Country | US
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Telephone | 386-241-1020
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Fax | 386-241-1022
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Provider Business Mailing Address
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Address Line | 311 N CLYDE MORRIS BLVD
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City | DAYTONA BEACH
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State | FL
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Zip | 32114-2781
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Country | US
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Telephone | 386-241-1020
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Fax | 386-241-1022
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number | APRN11034876
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | RN196865
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | AG02200003
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License Number State | TX
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