Basic Information
| Provider Information | |||||||||
| NPI: | 1659608719 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUDOURIS-POWERS | ||||||||
| FirstName: | ANGELA | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4235 SECOR RD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436234231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194733561 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4126 N HOLLAND SYLVANIA RD | ||||||||
| Address2: | STE 105 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436233536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194795605 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2009 | ||||||||
| LastUpdateDate: | 08/02/2017 | ||||||||
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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 | 363LA2200X | APRNCNP10984 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 3027021 | 05 | OH | MEDICAID |