Provider Demographics
NPI:1104646249
Name:BOUILLIART DE ST SYMPHORIEN, EMMANUELLE
Entity type:Individual
Prefix:
First Name:EMMANUELLE
Middle Name:
Last Name:BOUILLIART DE ST SYMPHORIEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 N BAYSHORE DR APT 3251
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33132-1167
Mailing Address - Country:US
Mailing Address - Phone:305-965-8859
Mailing Address - Fax:
Practice Address - Street 1:1717 N BAYSHORE DR APT 3251
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33132-1167
Practice Address - Country:US
Practice Address - Phone:305-965-8859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11035914363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily