Provider Demographics
NPI:1972125045
Name:BOUGHNER, STEPHANIE JEAN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JEAN
Last Name:BOUGHNER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:JEAN
Other - Last Name:SHARUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:136 CHERRYBARK WAY
Mailing Address - Street 2:
Mailing Address - City:CHOUDRANT
Mailing Address - State:LA
Mailing Address - Zip Code:71227-5030
Mailing Address - Country:US
Mailing Address - Phone:479-629-5360
Mailing Address - Fax:
Practice Address - Street 1:1603 GOODWIN RD
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-2907
Practice Address - Country:US
Practice Address - Phone:318-225-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-12
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10432R225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist