Provider Demographics
NPI:1619730108
Name:BOUGHNER, ANGELINE MARIE (CHW)
Entity Type:Individual
Prefix:MRS
First Name:ANGELINE
Middle Name:MARIE
Last Name:BOUGHNER
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5632 WISE RD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-3411
Mailing Address - Country:US
Mailing Address - Phone:517-243-5899
Mailing Address - Fax:
Practice Address - Street 1:2316 S CEDAR ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-3152
Practice Address - Country:US
Practice Address - Phone:517-702-3508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker