Provider Demographics
NPI:1366318149
Name:BOULAY, THERESE
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:BOULAY
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 1:15121 NW 7TH CT
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-1856
Mailing Address - Country:US
Mailing Address - Phone:786-303-9175
Mailing Address - Fax:
Practice Address - Street 1:11011 SHERIDAN ST STE 106
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33026-1501
Practice Address - Country:US
Practice Address - Phone:786-303-9175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-16
Last Update Date:2025-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11042947363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily