Provider Demographics
NPI:1346534864
Name:BOUDREAU, MICHELLE M (DO)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:BOUDREAU
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11215 METRO PKWY STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-1206
Mailing Address - Country:US
Mailing Address - Phone:239-208-2212
Mailing Address - Fax:
Practice Address - Street 1:11215 METRO PKWY STE 1
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1206
Practice Address - Country:US
Practice Address - Phone:239-208-2212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-01
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO1910762084N0400X
PAOD0190972084N0400X
NH188492084N0400X
ND150392084N0400X
OH34.0133302084N0400X
MI51010237282084N0400X
CT510082084N0400X
TXTM007562084N0400X
NY2937602084N0400X
MO20200058202084N0400X
FLOS150702084N0400X
CA174432084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3116006Medicaid