Provider Demographics
NPI:1376949586
Name:BOUDREAUX, AMANDA (RN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BOUDREAUX
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:MORGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:320 AKERS AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37665-1934
Mailing Address - Country:US
Mailing Address - Phone:972-890-7839
Mailing Address - Fax:
Practice Address - Street 1:320 AKERS AVE
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37665-1934
Practice Address - Country:US
Practice Address - Phone:972-890-7839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-16
Last Update Date:2014-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN201347163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse