Provider Demographics
NPI:1457990798
Name:BOIVIN, COURTNEY TAYLOR (NP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:TAYLOR
Last Name:BOIVIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12436 TESSON FERRY RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2702
Mailing Address - Country:US
Mailing Address - Phone:314-973-5177
Mailing Address - Fax:
Practice Address - Street 1:12436 TESSON FERRY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2702
Practice Address - Country:US
Practice Address - Phone:314-454-6336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-03
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019043941363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics