Provider Demographics
NPI:1639285216
Name:BOUDREAU, LYNETTE (DC)
Entity Type:Individual
Prefix:
First Name:LYNETTE
Middle Name:
Last Name:BOUDREAU
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4796 CANTON RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-3250
Mailing Address - Country:US
Mailing Address - Phone:770-926-9488
Mailing Address - Fax:770-924-7480
Practice Address - Street 1:4796 CANTON RD
Practice Address - Street 2:SUITE 400
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-3250
Practice Address - Country:US
Practice Address - Phone:770-926-9488
Practice Address - Fax:770-924-7480
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006159111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA479259Medicare UPIN
GA35ZCFWMedicare ID - Type Unspecified