Provider Demographics
NPI:1992762405
Name:BOUCHE, MICHELE K (CNM)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:K
Last Name:BOUCHE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3390
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3390
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:917 11TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-1578
Practice Address - Country:US
Practice Address - Phone:541-387-8940
Practice Address - Fax:541-387-8908
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR084055791N5367A00000X, 176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR069997Medicaid
OR042WCKLKAMedicare ID - Type Unspecified
ORR91959Medicare UPIN