Provider Demographics
NPI:1174214803
Name:BOUTTE, ALLISON MICHELLE
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:MICHELLE
Last Name:BOUTTE
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 1:9506 E STAFFORD ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67207-6653
Mailing Address - Country:US
Mailing Address - Phone:316-708-4524
Mailing Address - Fax:
Practice Address - Street 1:4401 WORNALL RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-3220
Practice Address - Country:US
Practice Address - Phone:816-932-3679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant