1548365984 NPI number — MS. PAMELA MARIE GOUDREAU CRNA

Table of content: MS. PAMELA MARIE GOUDREAU CRNA (NPI 1548365984)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548365984 NPI number — MS. PAMELA MARIE GOUDREAU CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOUDREAU
Provider First Name:
PAMELA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOULEY
Provider Other First Name:
PAMELA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1548365984
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/30/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
59 PAGE HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERLIN
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03570
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-752-2200
Provider Business Mailing Address Fax Number:
843-777-8705

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
AVH 59 PAGE HILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERLIN
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03570
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-752-2200
Provider Business Practice Location Address Fax Number:
843-777-8705
Provider Enumeration Date:
09/13/2006

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: 367500000X , with the licence number:  APN 3035 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 034214-23 , 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: AN1501 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com