Provider Demographics
NPI:1114386554
Name:BOUCHARD, ANDREA (CRNA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:CYR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:194 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT KENT
Mailing Address - State:ME
Mailing Address - Zip Code:04743-1428
Mailing Address - Country:US
Mailing Address - Phone:207-834-3155
Mailing Address - Fax:207-834-2949
Practice Address - Street 1:194 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT KENT
Practice Address - State:ME
Practice Address - Zip Code:04743-1428
Practice Address - Country:US
Practice Address - Phone:207-834-3155
Practice Address - Fax:207-834-2949
Is Sole Proprietor?:No
Enumeration Date:2016-02-13
Last Update Date:2019-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERN57585390200000X
MERNA163028367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program