Provider Demographics
NPI:1679356430
Name:BOUDOIN, NIA ELLYSE
Entity type:Individual
Prefix:
First Name:NIA
Middle Name:ELLYSE
Last Name:BOUDOIN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8440 W JUDGE PEREZ DR
Mailing Address - Street 2:
Mailing Address - City:CHALMETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70043-1616
Mailing Address - Country:US
Mailing Address - Phone:504-596-9520
Mailing Address - Fax:
Practice Address - Street 1:8440 W JUDGE PEREZ DR
Practice Address - Street 2:
Practice Address - City:CHALMETTE
Practice Address - State:LA
Practice Address - Zip Code:70043-1616
Practice Address - Country:US
Practice Address - Phone:504-596-9520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-16
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA234108363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily