Provider Demographics
NPI:1023192432
Name:BOUFFARD, CYNTHIA KAY (NP)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:KAY
Last Name:BOUFFARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 BRUCE RD
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441
Mailing Address - Country:US
Mailing Address - Phone:815-726-9397
Mailing Address - Fax:
Practice Address - Street 1:20960 S FRANKFORT SQUARE RD STE C
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-5127
Practice Address - Country:US
Practice Address - Phone:815-469-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001979363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00226129OtherRR MEDICARE
S66589Medicare UPIN
ILK16147Medicare ID - Type Unspecified
ILK16146Medicare ID - Type Unspecified