Provider Demographics
NPI:1821852112
Name:BOUCHILLON, AVERY
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:
Last Name:BOUCHILLON
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 1:22325 HIGHWAY 43
Mailing Address - Street 2:
Mailing Address - City:ETHEL
Mailing Address - State:MS
Mailing Address - Zip Code:39067-6037
Mailing Address - Country:US
Mailing Address - Phone:662-736-6927
Mailing Address - Fax:
Practice Address - Street 1:22325 HIGHWAY 43
Practice Address - Street 2:
Practice Address - City:ETHEL
Practice Address - State:MS
Practice Address - Zip Code:39067-6037
Practice Address - Country:US
Practice Address - Phone:662-736-6927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program