Provider Demographics
NPI:1841596608
Name:BOULWARE, SONDA SUE (ANP)
Entity Type:Individual
Prefix:
First Name:SONDA
Middle Name:SUE
Last Name:BOULWARE
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 S TELSHOR BLVD
Mailing Address - Street 2:STE 102
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-9148
Mailing Address - Country:US
Mailing Address - Phone:575-522-7247
Mailing Address - Fax:575-522-2029
Practice Address - Street 1:2525 S TELSHOR BLVD
Practice Address - Street 2:BUILDING 14, SUITE 102
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-5071
Practice Address - Country:US
Practice Address - Phone:575-522-7247
Practice Address - Fax:575-522-2029
Is Sole Proprietor?:No
Enumeration Date:2011-01-26
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-01702363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner