Provider Demographics
NPI:1154657443
Name:BOUTILIER, JENNA (NP)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:BOUTILIER
Suffix:
Gender:F
Credentials:NP
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 27
Mailing Address - Street 2:
Mailing Address - City:MANVILLE
Mailing Address - State:RI
Mailing Address - Zip Code:02838-0027
Mailing Address - Country:US
Mailing Address - Phone:800-927-0002
Mailing Address - Fax:
Practice Address - Street 1:106 NATE WHIPPLE HWY
Practice Address - Street 2:SUITE 101
Practice Address - City:CUMBERLAND
Practice Address - State:RI
Practice Address - Zip Code:02864-1403
Practice Address - Country:US
Practice Address - Phone:401-658-2020
Practice Address - Fax:401-658-3612
Is Sole Proprietor?:No
Enumeration Date:2009-10-22
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RINPP37529363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner