Provider Demographics
NPI:1386830966
Name:BOYTIM, JULIE MARIE (RN, CRNA)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:MARIE
Last Name:BOYTIM
Suffix:
Gender:F
Credentials:RN, CRNA
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:MARIE
Other - Last Name:LIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, CRNA
Mailing Address - Street 1:1737 BRIARCREST DR 14
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2739
Mailing Address - Country:US
Mailing Address - Phone:979-776-4777
Mailing Address - Fax:979-776-0588
Practice Address - Street 1:2411 FOUNTAIN VIEW DR
Practice Address - Street 2:STE 200
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77057-4817
Practice Address - Country:US
Practice Address - Phone:713-620-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX686777367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2104039Medicaid
TXP00821827OtherRAILROAD MEDICARE
TX191904502Medicaid
TX8L21461Medicare PIN