Provider Demographics
NPI:1376910521
Name:BOUCHARD, KELLEY ELIZABETH SMITH (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:ELIZABETH SMITH
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:3225 INTERNATIONAL CIRCLE SUITE 220
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910
Mailing Address - Country:US
Mailing Address - Phone:719-694-8956
Mailing Address - Fax:719-418-3578
Practice Address - Street 1:3225 INTERNATIONAL CIRCLE SUITE 220
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910
Practice Address - Country:US
Practice Address - Phone:719-694-8956
Practice Address - Fax:719-418-3578
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COC-APN.0000381-C-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily