Provider Demographics
NPI:1942735477
Name:BOULANGER, REBEKAH ELISABETH-CARRADINE
Entity Type:Individual
Prefix:
First Name:REBEKAH
Middle Name:ELISABETH-CARRADINE
Last Name:BOULANGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBEKAH
Other - Middle Name:ELISABETH-CARRADINE
Other - Last Name:BOULANGER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1234 NAPIER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2112
Mailing Address - Country:US
Mailing Address - Phone:269-983-8300
Mailing Address - Fax:
Practice Address - Street 1:1234 NAPIER AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2112
Practice Address - Country:US
Practice Address - Phone:269-983-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-21
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY04785207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine