Provider Demographics
NPI:1376507699
Name:BOULWARE, MARY ALICE (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:BOULWARE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 BLYTHE BLVD
Practice Address - Street 2:MEDICAL CENTER PLAZA SUITE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5866
Practice Address - Country:US
Practice Address - Phone:704-381-8840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5003612363L00000X
NC0050-03612363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMB08283691OtherCOMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH, DIVISION OF FOOD/DRUG
MARN2269303OtherCOMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
NCMB1668699OtherDEA
NC1376507699Medicaid
NCNP3969Medicaid
SCNP3969Medicaid
SCNP3969Medicaid