Provider Demographics
NPI:1669814513
Name:BOUDREAUX, KRISTI MCDONALD (NP-C)
Entity Type:Individual
Prefix:MS
First Name:KRISTI
Middle Name:MCDONALD
Last Name:BOUDREAUX
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4358
Mailing Address - Country:US
Mailing Address - Phone:704-874-1936
Mailing Address - Fax:704-865-4614
Practice Address - Street 1:154 GOVERNMENT CENTER DR
Practice Address - Street 2:
Practice Address - City:MOCKSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27028-6299
Practice Address - Country:US
Practice Address - Phone:336-477-2233
Practice Address - Fax:336-450-1744
Is Sole Proprietor?:No
Enumeration Date:2013-07-20
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07307363LF0000X, 363LP2300X
NC5018585363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2348256Medicaid
LA352410OtherMEDICARE