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General NPI Number Information
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NPI Number | 1881167047
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Entity Type | Individual
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Provider Name | HOLLY SUSAN BOUTWELL RN
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Gender | Female
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Dates
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Enumeration Date | 01/09/2019
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Last Update Date | 01/09/2019
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Provider Practice Location Address
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Address Line | 2105 E SOUTH BLVD
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City | MONTGOMERY
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State | AL
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Zip | 36116-2409
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Country | US
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Telephone | 334-286-2823
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Fax |
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Provider Business Mailing Address
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Address Line | 1535 COUNTY ROAD 37
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City | FITZPATRICK
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State | AL
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Zip | 36029-2909
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Country | US
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Telephone | 214-995-7979
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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 | 163WN0002X
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Taxonomy Name | Neonatal Intensive Care Registered Nurse
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License Number | 1-156485
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License Number State | AL
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