Provider Demographics
NPI:1649166984
Name:HEALTH BOUTIQUE
Entity type:Organization
Organization Name:HEALTH BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MHYKEISHA
Authorized Official - Middle Name:KATRESE
Authorized Official - Last Name:EVANS-GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:318-458-4523
Mailing Address - Street 1:203 TIMBERLAND RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70507-2746
Mailing Address - Country:US
Mailing Address - Phone:318-458-4523
Mailing Address - Fax:
Practice Address - Street 1:606 LATIOLAIS DR UNIT A
Practice Address - Street 2:
Practice Address - City:BREAUX BRIDGE
Practice Address - State:LA
Practice Address - Zip Code:70517-4231
Practice Address - Country:US
Practice Address - Phone:337-414-6463
Practice Address - Fax:337-414-6483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-13
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty