Provider Demographics
NPI:1003442906
Name:BOULLION, RENELLA (APRN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:RENELLA
Middle Name:
Last Name:BOULLION
Suffix:
Gender:F
Credentials:APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 OGLETREE DR
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351-6783
Mailing Address - Country:US
Mailing Address - Phone:936-328-8812
Mailing Address - Fax:
Practice Address - Street 1:400 OGLETREE DR
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-6783
Practice Address - Country:US
Practice Address - Phone:936-328-8812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP145643363LP0200X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP145643Medicaid
TXAP145643OtherPRIVATE INSURANCE