Provider Demographics
NPI:1346765450
Name:BOUDREAU, ANISSA (DC)
Entity Type:Individual
Prefix:
First Name:ANISSA
Middle Name:
Last Name:BOUDREAU
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 E TRANSIT ST APT 1
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-6314
Mailing Address - Country:US
Mailing Address - Phone:401-301-4940
Mailing Address - Fax:
Practice Address - Street 1:33 COLLEGE HILL RD STE 30C
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-2766
Practice Address - Country:US
Practice Address - Phone:401-846-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-09
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDCP00654111N00000X
NC04813111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor