Provider Demographics
NPI:1891019964
Name:BOUDAKIAN, MARTHA ANI (CNM)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:ANI
Last Name:BOUDAKIAN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 CLOVER ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-4517
Mailing Address - Country:US
Mailing Address - Phone:585-271-3323
Mailing Address - Fax:585-271-3324
Practice Address - Street 1:2425 CLOVER ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-4517
Practice Address - Country:US
Practice Address - Phone:585-271-3323
Practice Address - Fax:585-271-3324
Is Sole Proprietor?:No
Enumeration Date:2010-03-18
Last Update Date:2021-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF000745-1367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF000745-1OtherNYS MIDWIFE REGISTRATION CERTIFICATE