Provider Demographics
NPI:1255953626
Name:BOUDOIR, CARLA RENEA (CNP)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:RENEA
Last Name:BOUDOIR
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18342 KERRVILLE TRL
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-7310
Mailing Address - Country:US
Mailing Address - Phone:612-275-2739
Mailing Address - Fax:
Practice Address - Street 1:18342 KERRVILLE TRL
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-7310
Practice Address - Country:US
Practice Address - Phone:612-275-2739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-08
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7376363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner