Provider Demographics
NPI:1215786785
Name:BOULAY, MIRIAM (CRNA)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:BOULAY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6791 FAIRWAY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-1713
Mailing Address - Country:US
Mailing Address - Phone:774-444-0057
Mailing Address - Fax:
Practice Address - Street 1:2540 WINDY HILL RD SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8605
Practice Address - Country:US
Practice Address - Phone:470-644-1274
Practice Address - Fax:470-644-1119
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-16
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN250948367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered