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General NPI Number Information
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NPI Number | 1649880543
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Entity Type | Individual
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Provider Name | ALLISON JOY BOUTWELL PA-C
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Gender | Female
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Dates
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Enumeration Date | 08/05/2020
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Last Update Date | 04/28/2025
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Provider Practice Location Address
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Address Line | 50 PARKWAY LN STE 10
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City | PETAL
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State | MS
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Zip | 39465
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Country | US
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Telephone | 601-544-7404
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Fax | 601-584-6457
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Provider Business Mailing Address
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Address Line | 415 S 28TH AVE
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City | HATTIESBURG
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State | MS
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Zip | 39401-7246
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Country | US
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Telephone | 601-264-6000
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Fax |
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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