Provider Demographics
NPI:1609361013
Name:BOULTON, ADRIANA SUZANNE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:ADRIANA
Middle Name:SUZANNE
Last Name:BOULTON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 RIDGECREST DR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-3458
Mailing Address - Country:US
Mailing Address - Phone:575-496-5525
Mailing Address - Fax:
Practice Address - Street 1:5400 GIBSON BLVD SE STE 3B-200
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-5566
Practice Address - Country:US
Practice Address - Phone:505-982-3113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM74944363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health