Provider Demographics
NPI:1255690558
Name:BOUTON, RAQUEL
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:BOUTON
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 1:2 DOMINO WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNT SINAI
Mailing Address - State:NY
Mailing Address - Zip Code:11766-2715
Mailing Address - Country:US
Mailing Address - Phone:631-828-2882
Mailing Address - Fax:
Practice Address - Street 1:2 DOMINO WAY
Practice Address - Street 2:
Practice Address - City:MOUNT SINAI
Practice Address - State:NY
Practice Address - Zip Code:11766-2715
Practice Address - Country:US
Practice Address - Phone:631-828-2882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-08
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10303300164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse