MEDICARE: AMY BOUDONCK

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	2008023288	MO

General Provider Information

NPI Number	:	1295385888
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY BOUDONCK

Provider Business Mailing Address
First Line	:	16544 HUNTERS CROSSING DR
Second Line	:
City	:	WILDWOOD
State	:	MO
Zip	:	63040-1733
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1406 N 39TH ST
Second Line	:
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62204-2431
Country	:	US
Telephone Number	:	314-482-3706
Fax Number	:

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

Provider Enumeration Date	:	09/16/2019
Last Update Date	:	09/16/2019

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