Provider Demographics
NPI:1760905384
Name:BOUCHER, AMIE (NP-C)
Entity Type:Individual
Prefix:
First Name:AMIE
Middle Name:
Last Name:BOUCHER
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 1:9103 N 183RD LN
Mailing Address - Street 2:
Mailing Address - City:WADDELL
Mailing Address - State:AZ
Mailing Address - Zip Code:85355-4360
Mailing Address - Country:US
Mailing Address - Phone:623-888-2261
Mailing Address - Fax:
Practice Address - Street 1:1510 E FLOWER ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-5698
Practice Address - Country:US
Practice Address - Phone:602-954-0444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP10405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner