MEDICARE: DEANNA BOICOURT RN

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	163W00000X	Registered Nurse	FL1971772	FL

General Provider Information

NPI Number	:	1215680103
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEANNA BOICOURT RN

Provider Business Mailing Address
First Line	:	1717 N CLYDE MORRIS BLVD STE 130
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32117-5532
Country	:	US
Telephone Number	:	321-439-4174
Fax Number	:

Provider Business Practice Location Address
First Line	:	1717 N CLYDE MORRIS BLVD STE 130
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32117-5532
Country	:	US
Telephone Number	:	386-274-1004
Fax Number	:

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

Provider Enumeration Date	:	01/31/2022
Last Update Date	:	01/31/2022

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