Provider Demographics
NPI:1013358530
Name:BOULTS, DEIDRE ALLEN (FNP-C)
Entity Type:Individual
Prefix:MS
First Name:DEIDRE
Middle Name:ALLEN
Last Name:BOULTS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:DEIDRE
Other - Middle Name:MARSHA
Other - Last Name:ALLEN BOSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5360 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-6548
Mailing Address - Country:US
Mailing Address - Phone:225-757-1023
Mailing Address - Fax:225-757-1053
Practice Address - Street 1:5360 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-6548
Practice Address - Country:US
Practice Address - Phone:225-757-1023
Practice Address - Fax:225-757-1053
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-12
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07286363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily