Provider Demographics
NPI:1164137972
Name:BOUTELLE, CIERRA JEAN
Entity Type:Individual
Prefix:
First Name:CIERRA
Middle Name:JEAN
Last Name:BOUTELLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4391 SODA CREEK RD APT 4
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-1149
Mailing Address - Country:US
Mailing Address - Phone:608-290-3418
Mailing Address - Fax:
Practice Address - Street 1:4391 SODA CREEK RD APT 4
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-1149
Practice Address - Country:US
Practice Address - Phone:608-290-3418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer