MEDICARE: SUSAN MARIE BOUTTE NP

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	363LF0000X	Family Nurse Practitioner	694782	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00J21A	OTHER	TX	GROUP MEDICARE

General Provider Information

NPI Number	:	1457582272
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN MARIE BOUTTE NP

Provider Business Mailing Address
First Line	:	1400 HOLCOMBE BLVD
Second Line	:	UNIT 442
City	:	HOUSTON
State	:	TX
Zip	:	77030-4008
Country	:	US
Telephone Number	:	713-792-1942
Fax Number	:	713-794-4950

Provider Business Practice Location Address
First Line	:	1400 HOLCOMBE BLVD
Second Line	:	UNIT 442
City	:	HOUSTON
State	:	TX
Zip	:	77030-4008
Country	:	US
Telephone Number	:	713-792-1942
Fax Number	:	713-794-4950

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

Provider Enumeration Date	:	07/28/2009
Last Update Date	:	06/05/2012

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