Provider Demographics
NPI:1922416841
Name:BOUDREAUX, ALISHA
Entity Type:Individual
Prefix:
First Name:ALISHA
Middle Name:
Last Name:BOUDREAUX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALISHA
Other - Middle Name:SHANNON
Other - Last Name:BURRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN, PNP
Mailing Address - Street 1:2903 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-8809
Mailing Address - Country:US
Mailing Address - Phone:337-478-6480
Mailing Address - Fax:337-474-9637
Practice Address - Street 1:2903 1ST AVE
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8809
Practice Address - Country:US
Practice Address - Phone:337-478-6480
Practice Address - Fax:337-474-9637
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07984363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics