Basic Information
| Provider Information | |||||||||
| NPI: | 1033661996 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOYETTE | ||||||||
| FirstName: | CARLIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4109 HIGHWAY 98 W | ||||||||
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| City: | SUMMIT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396669132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012763900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 409 TYLER HOLMES DR | ||||||||
| Address2: | |||||||||
| City: | WINONA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389671521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622834114 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2016 | ||||||||
| LastUpdateDate: | 10/26/2016 | ||||||||
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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 | 224Z00000X | 3076 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.