Provider Demographics
NPI:1699750034
Name:BOUCHER, RENEE M (NP)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:M
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:M
Other - Last Name:JOLICOEUR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:242 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440-1336
Mailing Address - Country:US
Mailing Address - Phone:978-630-5076
Mailing Address - Fax:978-630-5078
Practice Address - Street 1:3 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:WINCHENDON
Practice Address - State:MA
Practice Address - Zip Code:01475-1279
Practice Address - Country:US
Practice Address - Phone:978-297-5052
Practice Address - Fax:978-297-5430
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA230888363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0714267Medicaid
MA0714267Medicaid
MANP4769Medicare PIN