Basic Information
Provider Information | |||||||||
NPI: | 1477062594 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOUCHARD | ||||||||
FirstName: | ANNA | ||||||||
MiddleName: | SWANSON | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | AGACNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 61 WHITCHER ST NE STE 3110 | ||||||||
Address2: |   | ||||||||
City: | MARIETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300601179 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 61 WHITCHER ST NE | ||||||||
Address2: |   | ||||||||
City: | MARIETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300601176 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7704222326 | ||||||||
FaxNumber: | 7704227797 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2017 | ||||||||
LastUpdateDate: | 10/15/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | RN164917 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
ID | Type | State | Issuer | Description | RN164917 | 01 | GA | APRN LICENSE | OTHER |