Provider Demographics
NPI:1558681734
Name:BOUTWELL, ANNA A
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:A
Last Name:BOUTWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 N FIREWEED ST STE A
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7593
Mailing Address - Country:US
Mailing Address - Phone:907-252-9875
Mailing Address - Fax:
Practice Address - Street 1:247 N FIREWEED ST STE A
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7593
Practice Address - Country:US
Practice Address - Phone:907-262-8597
Practice Address - Fax:907-262-6516
Is Sole Proprietor?:No
Enumeration Date:2010-06-10
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1158363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCE1671OtherRAILROAD MEDICARE
AKNP01136Medicaid
AKNP01136Medicaid