Provider Demographics
NPI:1205022217
Name:BOUCICAUT, ROSE MARTHE
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:MARTHE
Last Name:BOUCICAUT
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 1:216 PRAIRIE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11703-1002
Mailing Address - Country:US
Mailing Address - Phone:631-274-5509
Mailing Address - Fax:
Practice Address - Street 1:216 PRAIRIE DR
Practice Address - Street 2:
Practice Address - City:NORTH BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11703-1002
Practice Address - Country:US
Practice Address - Phone:631-274-5509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-24
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY561176-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02702692Medicaid