Provider Demographics
NPI:1841216504
Name:BOUCHILLON, VICKIE L (CRNA)
Entity Type:Individual
Prefix:MS
First Name:VICKIE
Middle Name:L
Last Name:BOUCHILLON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 551420
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33355-1420
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:954-839-2569
Practice Address - Street 1:1968 PEACHTREE RAOD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1218
Practice Address - Country:US
Practice Address - Phone:678-202-2074
Practice Address - Fax:770-590-1442
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN039767367500000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000718825JMedicaid
432CBJA87Medicare PIN
43ZCBJA87Medicare ID - Type Unspecified
S41078Medicare UPIN