Provider Demographics
NPI:1659674182
Name:BOUCHER, NICOLE LYNN (CPNP-PC)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:LYNN
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 KISSANE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-2467
Mailing Address - Country:US
Mailing Address - Phone:810-229-7337
Mailing Address - Fax:
Practice Address - Street 1:136 KISSANE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-2467
Practice Address - Country:US
Practice Address - Phone:810-229-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-05
Last Update Date:2010-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704195198363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics