Provider Demographics
NPI:1053325621
Name:BOUDREAU, ELLEN FLORENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:FLORENCE
Last Name:BOUDREAU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6405 CARDINAL LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-4020
Mailing Address - Country:US
Mailing Address - Phone:301-452-7115
Mailing Address - Fax:
Practice Address - Street 1:6405 CARDINAL LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-4020
Practice Address - Country:US
Practice Address - Phone:301-452-7115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0035540171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider