1568029585 NPI number — MOLLY GRAVES BOUDREAU FNP

Table of content: MOLLY GRAVES BOUDREAU FNP (NPI 1568029585)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568029585 NPI number — MOLLY GRAVES BOUDREAU FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUDREAU
Provider First Name:
MOLLY
Provider Middle Name:
GRAVES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRAVES
Provider Other First Name:
MOLLY
Provider Other Middle Name:
JANE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1568029585
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
173 MIDDLE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANCASTER
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03584-3508
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-788-5029
Provider Business Mailing Address Fax Number:
603-788-5607

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8 CLOVER LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITEFIELD
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03598-3343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-788-5095
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/24/2019

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:  RN2309489 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 086566-23 , 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: 110154496A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".