Provider Demographics
NPI:1568488419
Name:BOUCHER, NAN J (FNP)
Entity Type:Individual
Prefix:
First Name:NAN
Middle Name:J
Last Name:BOUCHER
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 1:39 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:SO PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6143
Mailing Address - Country:US
Mailing Address - Phone:207-761-0650
Mailing Address - Fax:207-761-8198
Practice Address - Street 1:50 MARQUIS RD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:ME
Practice Address - Zip Code:04032-6477
Practice Address - Country:US
Practice Address - Phone:207-865-6131
Practice Address - Fax:207-865-9399
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER028338363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30347280Medicaid
ME337470099Medicaid
NH30347280Medicaid
ME337470099Medicaid
R90376Medicare UPIN