Provider Demographics
NPI:1588493753
Name:BOUGIE CHIC BEAUTY BAR AND AESTHETICS
Entity type:Organization
Organization Name:BOUGIE CHIC BEAUTY BAR AND AESTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:954-440-5326
Mailing Address - Street 1:674 N UNIVERSITY DR # 35
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-6738
Mailing Address - Country:US
Mailing Address - Phone:954-440-5326
Mailing Address - Fax:
Practice Address - Street 1:674 N UNIVERSITY DR # 35
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6738
Practice Address - Country:US
Practice Address - Phone:954-440-5326
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty