Provider Demographics
NPI:1922453240
Name:BOULTON, MANDY
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:BOULTON
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 1:9 HANOVER ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766-1312
Mailing Address - Country:US
Mailing Address - Phone:603-448-0126
Mailing Address - Fax:
Practice Address - Street 1:122 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:NH
Practice Address - Zip Code:03743-2679
Practice Address - Country:US
Practice Address - Phone:603-542-5449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH307750Medicaid
NH307750Medicaid