Provider Demographics
NPI:1194729913
Name:BOUDREAU, AMY (APRN)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:
Last Name:BOUDREAU
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 1:115 TECHNOLOGY DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-6337
Mailing Address - Country:US
Mailing Address - Phone:203-445-7093
Mailing Address - Fax:203-445-7094
Practice Address - Street 1:115 TECHNOLOGY DR
Practice Address - Street 2:SUITE 300
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-6337
Practice Address - Country:US
Practice Address - Phone:203-445-7093
Practice Address - Fax:203-445-7094
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002411363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT500001295Medicare PIN
CTQ20003Medicare UPIN