Provider Demographics
NPI:1871033571
Name:BOUCHER, CAROLINE
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:BOUCHER
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 1:7304 AVENUE T
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-6237
Mailing Address - Country:US
Mailing Address - Phone:407-757-5505
Mailing Address - Fax:347-312-4136
Practice Address - Street 1:675 3RD AVE
Practice Address - Street 2:5TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-5704
Practice Address - Country:US
Practice Address - Phone:407-757-5505
Practice Address - Fax:347-312-4136
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9427482163W00000X
NY714565163W00000X
NYF353842-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse