Provider Demographics
NPI:1851843668
Name:BOUCUVALAS, NICOLE CHRISTINE (CNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:CHRISTINE
Last Name:BOUCUVALAS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 N MAIN ST STE 130
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-2100
Mailing Address - Country:US
Mailing Address - Phone:937-433-5309
Mailing Address - Fax:937-247-5154
Practice Address - Street 1:825 N MAIN ST STE 130
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-2100
Practice Address - Country:US
Practice Address - Phone:937-433-5309
Practice Address - Fax:937-424-3650
Is Sole Proprietor?:No
Enumeration Date:2016-10-27
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.020071363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0190775Medicaid
OHH522020OtherMEDICARE
OH$$$$$$$$$00OtherBWC
OH$$$$$$$$$00OtherBWC