Basic Information
| Provider Information | |||||||||
| NPI: | 1003884685 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUCHARD | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40 | ||||||||
| Address2: | |||||||||
| City: | CARIBOU | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047360040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074982359 | ||||||||
| FaxNumber: | 2074983947 | ||||||||
| Practice Location | |||||||||
| Address1: | 163 VAN BUREN RD STE 4 | ||||||||
| Address2: | |||||||||
| City: | CARIBOU | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047363567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074986921 | ||||||||
| FaxNumber: | 2074981697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 09/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN27700 | ME | N | Nursing Service Providers | Registered Nurse | 176B00000X | CNM82022 | ME | Y | Other Service Providers | Midwife |
ID Information
| ID | Type | State | Issuer | Description | 11459629 | 01 | ME | CAQH ID NO. | OTHER | 8891249 | 01 | CIGNA PROVIDER ID NO. | OTHER | 2426723 | 01 | UNITED HEALTHCARE PROVIDER NO. | OTHER |