Provider Demographics
NPI:1285183137
Name:BOISSONEAULT, BRUCE I
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:BOISSONEAULT
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1829 BAUER AVE
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-5029
Mailing Address - Country:US
Mailing Address - Phone:419-626-0200
Mailing Address - Fax:419-626-0200
Practice Address - Street 1:1829 BAUER AVE
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-5029
Practice Address - Country:US
Practice Address - Phone:419-626-0200
Practice Address - Fax:419-626-0200
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide