Provider Demographics
NPI:1457582272
Name:BOUTTE, SUSAN MARIE (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:BOUTTE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:BROUSSARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 HOLCOMBE BLVD
Mailing Address - Street 2:UNIT 442
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-4008
Mailing Address - Country:US
Mailing Address - Phone:713-792-1942
Mailing Address - Fax:713-794-4950
Practice Address - Street 1:1400 HOLCOMBE BLVD
Practice Address - Street 2:UNIT 442
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4008
Practice Address - Country:US
Practice Address - Phone:713-792-1942
Practice Address - Fax:713-794-4950
Is Sole Proprietor?:No
Enumeration Date:2009-07-28
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX694782363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00J21AOtherGROUP MEDICARE
TX8L17557Medicare PIN