Provider Demographics
NPI:1629258009
Name:BOULIER, KELLY ANN (RN)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:BOULIER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 396
Mailing Address - Street 2:
Mailing Address - City:OLD FORGE
Mailing Address - State:NY
Mailing Address - Zip Code:13420-0396
Mailing Address - Country:US
Mailing Address - Phone:315-369-3269
Mailing Address - Fax:
Practice Address - Street 1:9000 MOOSE RIVER ROAD
Practice Address - Street 2:
Practice Address - City:FORESTPORT
Practice Address - State:NY
Practice Address - Zip Code:13338
Practice Address - Country:US
Practice Address - Phone:315-369-3269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY483271-1374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide