Provider Demographics
NPI:1568029585
Name:BOUDREAU, MOLLY GRAVES (FNP)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:GRAVES
Last Name:BOUDREAU
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:JANE
Other - Last Name:GRAVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:173 MIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:NH
Mailing Address - Zip Code:03584-3508
Mailing Address - Country:US
Mailing Address - Phone:603-788-5029
Mailing Address - Fax:603-788-5607
Practice Address - Street 1:8 CLOVER LN
Practice Address - Street 2:
Practice Address - City:WHITEFIELD
Practice Address - State:NH
Practice Address - Zip Code:03598-3343
Practice Address - Country:US
Practice Address - Phone:603-788-5095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-24
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2309489363L00000X
NH086566-23363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110154496AMedicaid