Provider Demographics
NPI:1326487406
Name:BOUTON, MICHELLE (LAC, MAOM)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BOUTON
Suffix:
Gender:F
Credentials:LAC, MAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-3844
Mailing Address - Country:US
Mailing Address - Phone:423-612-7494
Mailing Address - Fax:423-722-9333
Practice Address - Street 1:111 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-3844
Practice Address - Country:US
Practice Address - Phone:423-612-7494
Practice Address - Fax:423-722-9333
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-21
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNACU0000000207171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist