1508530189 NPI number — DR. SUSANNAH FRANCES BOUCHARD WHNP

Table of content: DR. SUSANNAH FRANCES BOUCHARD WHNP (NPI 1508530189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508530189 NPI number — DR. SUSANNAH FRANCES BOUCHARD WHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUCHARD
Provider First Name:
SUSANNAH
Provider Middle Name:
FRANCES
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
WHNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WINSLEY
Provider Other First Name:
SUSANNAH
Provider Other Middle Name:
FRANCES
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508530189
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2555 N 149TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOODYEAR
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85395-1692
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-499-3848
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4175 S. ALAMO AVE
Provider Second Line Business Practice Location Address:
BLDG 400
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85707-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-228-2778
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/06/2021

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: 363LW0102X , with the licence number:  259659 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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