Provider Demographics
NPI:1790554400
Name:BOUCHARD, CAITLIN ELIZABETH
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:ELIZABETH
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 CEDAR LAKE RD
Mailing Address - Street 2:
Mailing Address - City:DEEP RIVER
Mailing Address - State:CT
Mailing Address - Zip Code:06417-1527
Mailing Address - Country:US
Mailing Address - Phone:860-575-6539
Mailing Address - Fax:
Practice Address - Street 1:25 WELLS ST
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891-2934
Practice Address - Country:US
Practice Address - Phone:401-596-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-21
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRN77320163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency