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General NPI Number Information
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NPI Number | 1699231894
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Entity Type | Individual
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Provider Name | NICOLE M BOUDREAUX PA-C
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Gender | Female
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Dates
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Enumeration Date | 02/13/2019
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Last Update Date | 12/27/2023
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Provider Practice Location Address
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Address Line | 12302 SOMERSET AVE STE AB
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City | PRINCESS ANNE
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State | MD
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Zip | 21853-3099
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Country | US
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Telephone | 410-651-0300
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Fax |
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Provider Business Mailing Address
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Address Line | 34 GATEHOUSE TRL
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City | BERLIN
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State | MD
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Zip | 21811-2023
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Country | US
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Telephone | 410-490-9292
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | C0007122
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | C0007122
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License Number State | MD
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