Provider Demographics
NPI:1801510912
Name:BOUCHARD, ELISE (FNP-C)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:BOUCHARD
Suffix:
Gender:F
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 1:2074 FRDRCK DGLS BLVD APT 2C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026-3299
Mailing Address - Country:US
Mailing Address - Phone:315-727-3051
Mailing Address - Fax:
Practice Address - Street 1:1000 10TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1147
Practice Address - Country:US
Practice Address - Phone:315-727-3051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY350065363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily