Provider Demographics
NPI:1205693173
Name:BOUSHIE, PAMELA
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:BOUSHIE
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 1:125 LASALLE RD STE 208
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2311
Mailing Address - Country:US
Mailing Address - Phone:860-906-1289
Mailing Address - Fax:
Practice Address - Street 1:1131 WEST ST STE 2
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-6006
Practice Address - Country:US
Practice Address - Phone:860-517-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000743133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered