Provider Demographics
NPI:1073031548
Name:BOUCHER, HEATHER R (LPN)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:R
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 W MORENCI ST APT A
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:OH
Mailing Address - Zip Code:43533-9651
Mailing Address - Country:US
Mailing Address - Phone:419-250-0794
Mailing Address - Fax:
Practice Address - Street 1:600 FREEDOM DR
Practice Address - Street 2:
Practice Address - City:NAPOLEON
Practice Address - State:OH
Practice Address - Zip Code:43545-9038
Practice Address - Country:US
Practice Address - Phone:419-599-1660
Practice Address - Fax:419-592-8336
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-06
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.143581.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse