Provider Demographics
NPI:1093870404
Name:BOULAIS, NANNETTE M (LMT)
Entity Type:Individual
Prefix:MS
First Name:NANNETTE
Middle Name:M
Last Name:BOULAIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 TRUMAN AVE
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-2373
Mailing Address - Country:US
Mailing Address - Phone:352-250-4696
Mailing Address - Fax:352-751-1281
Practice Address - Street 1:10935 SE 177TH PL
Practice Address - Street 2:SUITE 306
Practice Address - City:SUMMERFIELD
Practice Address - State:FL
Practice Address - Zip Code:34491-8975
Practice Address - Country:US
Practice Address - Phone:352-250-4696
Practice Address - Fax:352-751-1280
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA41482225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC3856OtherBC BS