MEDICARE: MS. AMY BOUDREAU APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	002411	CT

General Provider Information

NPI Number	:	1194729913
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AMY BOUDREAU APRN

Provider Business Mailing Address
First Line	:	115 TECHNOLOGY DR
Second Line	:	SUITE 300
City	:	TRUMBULL
State	:	CT
Zip	:	06611-6337
Country	:	US
Telephone Number	:	203-445-7093
Fax Number	:	203-445-7094

Provider Business Practice Location Address
First Line	:	115 TECHNOLOGY DR
Second Line	:	SUITE 300
City	:	TRUMBULL
State	:	CT
Zip	:	06611-6337
Country	:	US
Telephone Number	:	203-445-7093
Fax Number	:	203-445-7094

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	04/01/2015

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