Provider Demographics
NPI:1992283782
Name:BOUCHIE, LAUREN NICOLE (PA)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:NICOLE
Last Name:BOUCHIE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:NICOLE
Other - Last Name:CARDINAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 760
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47501-0760
Mailing Address - Country:US
Mailing Address - Phone:812-254-7310
Mailing Address - Fax:812-257-8062
Practice Address - Street 1:1805 S STATE ROAD 57
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IN
Practice Address - Zip Code:47501-4326
Practice Address - Country:US
Practice Address - Phone:812-254-7845
Practice Address - Fax:812-254-5989
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002473A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1002473AOtherINDIANA LICENCES