Provider Demographics
NPI:1144588294
Name:BOUCHARD, KERRI L (ACNP-BC)
Entity type:Individual
Prefix:MS
First Name:KERRI
Middle Name:L
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S PACA ST FL 3
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1642
Mailing Address - Country:US
Mailing Address - Phone:443-926-1293
Mailing Address - Fax:410-328-8981
Practice Address - Street 1:16 S EUTAW ST FL 3
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1606
Practice Address - Country:US
Practice Address - Phone:410-328-3100
Practice Address - Fax:410-328-8981
Is Sole Proprietor?:No
Enumeration Date:2012-04-26
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR130529163W00000X, 363LC0200X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD067423100Medicaid
MDS062-0536OtherCAREFIRST BC/BS
MD067423100Medicaid