Provider Demographics
NPI:1881249779
Name:BOUCHARD, LAURA MAE (RN)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MAE
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:MAE
Other - Last Name:NICHOLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:95 CANYON DR
Mailing Address - Street 2:
Mailing Address - City:MILLINOCKET
Mailing Address - State:ME
Mailing Address - Zip Code:04462-2328
Mailing Address - Country:US
Mailing Address - Phone:297-731-4419
Mailing Address - Fax:
Practice Address - Street 1:50 SUMMER ST
Practice Address - Street 2:
Practice Address - City:MILLINOCKET
Practice Address - State:ME
Practice Address - Zip Code:04462-1400
Practice Address - Country:US
Practice Address - Phone:366-866-5842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-07
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERN68788163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management