Provider Demographics
NPI:1063441442
Name:BOUDREAUX, ALICE S (CRNA)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:S
Last Name:BOUDREAUX
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:MAY
Other - Last Name:SHEALEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-3755
Mailing Address - Fax:517-787-4146
Practice Address - Street 1:1514 JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70121-2429
Practice Address - Country:US
Practice Address - Phone:504-842-3755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN052095367500000X
LAAP01483367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1971456Medicaid
MS05423715Medicaid
LA56507Medicare PIN