Provider Demographics
NPI:1386959435
Name:BOUCHER, ELAINE RUSSO (NP)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:RUSSO
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:CAMILE
Other - Last Name:BOUCHER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:720 HARRISON AVE
Mailing Address - Street 2:DOB 503
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:850 HARRISON AVE
Practice Address - Street 2:YACC 4
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-4001
Practice Address - Country:US
Practice Address - Phone:617-414-2080
Practice Address - Fax:617-414-2090
Is Sole Proprietor?:No
Enumeration Date:2010-08-13
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN106293363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110086937AMedicaid
MA110086937AMedicaid