Provider Demographics
NPI:1265799340
Name:BOUTON, LORI M (APN)
Entity type:Individual
Prefix:MISS
First Name:LORI
Middle Name:M
Last Name:BOUTON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1329 WEST ANDREW JOHNSON HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814-3728
Mailing Address - Country:US
Mailing Address - Phone:423-581-8844
Mailing Address - Fax:423-318-3050
Practice Address - Street 1:1329 WEST ANDREW JOHNSON HWY
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-3728
Practice Address - Country:US
Practice Address - Phone:423-581-8844
Practice Address - Fax:423-318-3050
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-13
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000015681363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1528819Medicaid
TN103I506102Medicare PIN