Provider Demographics
NPI:1700084555
Name:BOUELE MBOULE, ANNE ROSETTE (MD)
Entity Type:Individual
Prefix:MISS
First Name:ANNE
Middle Name:ROSETTE
Last Name:BOUELE MBOULE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 N COLLINS ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76011-2659
Mailing Address - Country:US
Mailing Address - Phone:817-704-7339
Mailing Address - Fax:682-558-8008
Practice Address - Street 1:2301 N COLLINS ST
Practice Address - Street 2:SUITE 100
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-2659
Practice Address - Country:US
Practice Address - Phone:817-704-7339
Practice Address - Fax:682-558-8008
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL29656208000000X
TXP6342208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX218565403Medicaid
AL116029Medicaid
TX218565401Medicaid