Provider Demographics
NPI:1790844850
Name:BOULET, KATHY ANN (DC)
Entity Type:Individual
Prefix:DR
First Name:KATHY
Middle Name:ANN
Last Name:BOULET
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 MAIN ST
Mailing Address - Street 2:SUITE 18
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5802
Mailing Address - Country:US
Mailing Address - Phone:207-782-1171
Mailing Address - Fax:207-782-6176
Practice Address - Street 1:675 MAIN ST
Practice Address - Street 2:SUITE 18
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5802
Practice Address - Country:US
Practice Address - Phone:207-782-1171
Practice Address - Fax:207-782-6176
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR779111N00000X
MO005842111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME620070401OtherCIGNA INDIVIDUAL NO.
ME018172OtherANTHEM BLUE CROSS AND BS
ME620063501OtherCIGNA GROUP NO.
ME350052598OtherRAILROAD MEDICARE
MEM23107OtherCIGNA HMO NO.
ME0075OtherHARVARD PILGRIM HEALTHCAR
ME4404011OtherUNITED HEALTHCARE
ME620063501OtherCIGNA GROUP NO.
MEM23107OtherCIGNA HMO NO.
ME620070401OtherCIGNA INDIVIDUAL NO.