Provider Demographics
NPI:1023666096
Name:BOUCHARD, KIMBERLY RENEE (RN, AEMT)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:RENEE
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:RN, AEMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 W CHERRY AVE
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-1606
Mailing Address - Country:US
Mailing Address - Phone:616-566-8112
Mailing Address - Fax:
Practice Address - Street 1:3285 122ND AVE
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-9511
Practice Address - Country:US
Practice Address - Phone:269-673-6617
Practice Address - Fax:269-686-5260
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1645682146M00000X
MI4704305934163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate