Provider Demographics
NPI:1770568727
Name:BOULDIN, DOUGLAS ALLEN (FNP-C)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:ALLEN
Last Name:BOULDIN
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13353 OLIVE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3108
Mailing Address - Country:US
Mailing Address - Phone:636-473-8873
Mailing Address - Fax:
Practice Address - Street 1:13353 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3108
Practice Address - Country:US
Practice Address - Phone:636-473-8873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113431363L00000X
KY3009332363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO425690617Medicaid
MO425690617Medicaid
MO425690617Medicaid