Provider Demographics
NPI:1740430768
Name:BOUTET, KILLMAN JOSUE (RN)
Entity Type:Individual
Prefix:
First Name:KILLMAN
Middle Name:JOSUE
Last Name:BOUTET
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3863 LAKE KATHY RD
Mailing Address - Street 2:
Mailing Address - City:TUNNEL HILL
Mailing Address - State:GA
Mailing Address - Zip Code:30755-9716
Mailing Address - Country:US
Mailing Address - Phone:706-516-4229
Mailing Address - Fax:
Practice Address - Street 1:921 EAST THIRD STREET
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2165
Practice Address - Country:US
Practice Address - Phone:423-209-8306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-26
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN164849163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse