1194155242 NPI number — MS. LAURIE BOUTIN ARNP

Table of content: MS. LAURIE BOUTIN ARNP (NPI 1194155242)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194155242 NPI number — MS. LAURIE BOUTIN ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUTIN
Provider First Name:
LAURIE
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194155242
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3073 WHITE MOUNTAIN HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH CONWAY
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03860-7101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-356-5461
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MEMORIAL HOSPITAL
Provider Second Line Business Practice Location Address:
3073 WHITE MOUNTAIN HWY.
Provider Business Practice Location Address City Name:
NORTH CONWAY
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03860
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-356-5461
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/26/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  CNP191189 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: ARNP2085992 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 081101-23 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 010875000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".