Provider Demographics
NPI:1669445359
Name:BOUDRIEAU, JEANNE M (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:JEANNE
Middle Name:M
Last Name:BOUDRIEAU
Suffix:
Gender:F
Credentials:ARNP
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Mailing Address - Street 1:1450 NORTHWEST LN SE
Mailing Address - Street 2:PROVIDENCE ST. PETER CLINIC AT PANORAMA
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-6908
Mailing Address - Country:US
Mailing Address - Phone:360-491-4460
Mailing Address - Fax:360-491-3090
Practice Address - Street 1:1450 NORTHWEST LN SE
Practice Address - Street 2:PROVIDENCE ST. PETER CLINIC AT PANORAMA
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-6908
Practice Address - Country:US
Practice Address - Phone:360-491-4460
Practice Address - Fax:360-491-3090
Is Sole Proprietor?:No
Enumeration Date:2006-02-11
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAAP30004530363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9621798Medicaid
WAS53011Medicare UPIN
WA9621798Medicaid