Provider Demographics
NPI:1912883265
Name:BOUDREAU, MELINDA
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:BOUDREAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:
Other - Last Name:WALSER-BOUDREAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12635 EVINGTON POINT DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-4060
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12635 EVINGTON POINT DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579-4060
Practice Address - Country:US
Practice Address - Phone:813-394-7907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-13
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11041605363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner