Provider Demographics
NPI:1063000669
Name:BOULWARE, LINDA GEORGETTE (APRN)
Entity type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:GEORGETTE
Last Name:BOULWARE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1591 ABBOTT ST
Mailing Address - Street 2:
Mailing Address - City:CARLYLE
Mailing Address - State:IL
Mailing Address - Zip Code:62231-1107
Mailing Address - Country:US
Mailing Address - Phone:618-741-8431
Mailing Address - Fax:
Practice Address - Street 1:2045 W GRAND AVE STE B
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-1577
Practice Address - Country:US
Practice Address - Phone:888-660-4425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.022606363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily