Provider Demographics
NPI:1568468353
Name:BOUDREAUX, TINA MARIE (FNP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:BOUDREAUX
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2390 W CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-4205
Mailing Address - Country:US
Mailing Address - Phone:337-261-6100
Mailing Address - Fax:337-261-6102
Practice Address - Street 1:2390 W CONGRESS ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-4205
Practice Address - Country:US
Practice Address - Phone:337-261-6100
Practice Address - Fax:337-261-6102
Is Sole Proprietor?:No
Enumeration Date:2005-06-26
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN101634AP04563363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily