Provider Demographics
NPI:1922578640
Name:BOULWARE, ERICA
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:BOULWARE
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 1:770 ATLANTIC ST SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-3739
Mailing Address - Country:US
Mailing Address - Phone:202-638-9864
Mailing Address - Fax:
Practice Address - Street 1:4638 H ST SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-4981
Practice Address - Country:US
Practice Address - Phone:202-243-0693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC$$$$$$$$$Medicaid