Provider Demographics
NPI:1629142591
Name:BOULLIE, PATRICIA ANN (CNM)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:ANN
Last Name:BOULLIE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35242 KEE LN
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-8314
Mailing Address - Country:US
Mailing Address - Phone:503-325-4264
Mailing Address - Fax:
Practice Address - Street 1:550 22ND ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3312
Practice Address - Country:US
Practice Address - Phone:503-338-7595
Practice Address - Fax:503-325-4905
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR096007245ZN5367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR096009245ZN5OtherNURSING LICENSE NUMBER
OR83621Medicaid
WA9618216Medicaid
WA9618216Medicaid
S29932Medicare UPIN
OR83621Medicaid