Provider Demographics
NPI:1619285814
Name:BOUCICAULT, GERTHA
Entity Type:Individual
Prefix:
First Name:GERTHA
Middle Name:
Last Name:BOUCICAULT
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 1:21211 102ND AVE
Mailing Address - Street 2:APT. C4
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-1106
Mailing Address - Country:US
Mailing Address - Phone:718-468-8298
Mailing Address - Fax:
Practice Address - Street 1:21211 102ND AVE
Practice Address - Street 2:APT. C4
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11429-1106
Practice Address - Country:US
Practice Address - Phone:718-468-8298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-22
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY573530163W00000X
NYF345182-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse