Basic Information
| Provider Information | |||||||||
| NPI: | 1023192432 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUFFARD | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | KAY | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 510 BRUCE RD | ||||||||
| Address2: | |||||||||
| City: | LOCKPORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157269397 | ||||||||
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| Practice Location | |||||||||
| Address1: | 20960 S FRANKFORT SQUARE RD STE C | ||||||||
| Address2: | |||||||||
| City: | FRANKFORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604235127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154697100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 08/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209001979 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | P00226129 | 01 | IL | RR MEDICARE | OTHER |