Basic Information
| Provider Information | |||||||||
| NPI: | 1023666096 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUCHARD | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | RN, AEMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 W CHERRY AVE | ||||||||
| Address2: | |||||||||
| City: | ZEELAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494641606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6165668112 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3285 122ND AVE | ||||||||
| Address2: | |||||||||
| City: | ALLEGAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490109511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696736617 | ||||||||
| FaxNumber: | 2696865260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2019 | ||||||||
| LastUpdateDate: | 09/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146M00000X | 1645682 | MI | N | Emergency Medical Service Providers | Emergency Medical Technician, Intermediate | 163WP0808X | 4704305934 | MI | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.