1497862031 NPI number — DENISE JEAN BOUDREAUX-NIPPERT MD

Table of content: DENISE JEAN BOUDREAUX-NIPPERT MD (NPI 1497862031)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497862031 NPI number — DENISE JEAN BOUDREAUX-NIPPERT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUDREAUX-NIPPERT
Provider First Name:
DENISE
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOUDREAUX
Provider Other First Name:
DENISE
Provider Other Middle Name:
J.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1497862031
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3584 W 9000 S
Provider Second Line Business Mailing Address:
SUITE 206
Provider Business Mailing Address City Name:
WEST JORDAN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84088-5710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-561-2227
Provider Business Mailing Address Fax Number:
801-561-5353

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3584 W 9000 S
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
WEST JORDAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84088-5710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-561-2227
Provider Business Practice Location Address Fax Number:
801-561-5353
Provider Enumeration Date:
08/23/2006

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: 207V00000X , with the licence number:  5414306-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8462897 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 247321 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 212969 . This is a "LABOR & IND. WA STATE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8942479 . This is a "CRIME VICTIMS WA STATE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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