Provider Demographics
NPI:1013268218
Name:BOUTHILLETTE, SAMANTHA LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LYNN
Last Name:BOUTHILLETTE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:SAMANTHA
Other - Middle Name:LYNN
Other - Last Name:WHALEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:9 BRENDA DR
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01085-4601
Mailing Address - Country:US
Mailing Address - Phone:413-454-2782
Mailing Address - Fax:
Practice Address - Street 1:300 BIRNIE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1107
Practice Address - Country:US
Practice Address - Phone:413-785-4666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-27
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2833363AS0400X
MAPA5512363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical