Provider Demographics
NPI:1457769358
Name:EDIE BOUDREAUX LLC
Entity Type:Organization
Organization Name:EDIE BOUDREAUX LLC
Other - Org Name:EDIE B. POURCIAU, NP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:EDIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:POURCIAU
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC, ANP-BC
Authorized Official - Phone:337-608-9922
Mailing Address - Street 1:PO BOX 9227
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70562-9227
Mailing Address - Country:US
Mailing Address - Phone:337-608-9922
Mailing Address - Fax:337-608-9933
Practice Address - Street 1:124 E MAIN ST STE 104
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560-3725
Practice Address - Country:US
Practice Address - Phone:337-608-9922
Practice Address - Fax:337-608-9933
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDIE BOUDREAUX LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-24
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No251J00000XAgenciesNursing CareGroup - Multi-Specialty
No305S00000XManaged Care OrganizationsPoint of ServiceGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1309877Medicaid
LA3A664Medicare PIN