Provider Demographics
NPI:1497862031
Name:BOUDREAUX-NIPPERT, DENISE JEAN (MD)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:JEAN
Last Name:BOUDREAUX-NIPPERT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DENISE
Other - Middle Name:J
Other - Last Name:BOUDREAUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3584 W 9000 S
Mailing Address - Street 2:SUITE 206
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-5710
Mailing Address - Country:US
Mailing Address - Phone:801-561-2227
Mailing Address - Fax:801-561-5353
Practice Address - Street 1:3584 W 9000 S
Practice Address - Street 2:SUITE 206
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-5710
Practice Address - Country:US
Practice Address - Phone:801-561-2227
Practice Address - Fax:801-561-5353
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5414306-1205207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8462897Medicaid
OR247321Medicaid
WA212969OtherLABOR & IND. WA STATE
WA8942479OtherCRIME VICTIMS WA STATE
OR247321Medicaid
WA8942479OtherCRIME VICTIMS WA STATE