Provider Demographics
NPI:1033157227
Name:BOUCHER, NAN M (ANP)
Entity Type:Individual
Prefix:MS
First Name:NAN
Middle Name:M
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 95000 LBX 7650
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:99 CAMPUS AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-6045
Practice Address - Country:US
Practice Address - Phone:207-777-8810
Practice Address - Fax:207-777-8155
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAP081044363LG0600X
MECNP81044363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30347091Medicaid
ME432184299Medicaid
MENP536601Medicare PIN