Provider Demographics
NPI:1861459794
Name:BOUDOIN, STACEY W (NP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:W
Last Name:BOUDOIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 LAFITTE ST
Mailing Address - Street 2:STE B
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-5269
Mailing Address - Country:US
Mailing Address - Phone:985-624-5305
Mailing Address - Fax:
Practice Address - Street 1:635 LAFITTE ST STE B
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-5269
Practice Address - Country:US
Practice Address - Phone:985-624-5305
Practice Address - Fax:985-624-8643
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN072251363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1468584Medicaid
MS04002873Medicaid
LA1468584Medicaid
LA4H232Medicare ID - Type Unspecified