Provider Demographics
NPI:1538255880
Name:BOULTON, MARTHA (APRN, BC, MS, MSN)
Entity type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:
Last Name:BOULTON
Suffix:
Gender:F
Credentials:APRN, BC, MS, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:468 POST RD E
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-4441
Mailing Address - Country:US
Mailing Address - Phone:203-454-0505
Mailing Address - Fax:203-454-1115
Practice Address - Street 1:468 POST RD E
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-4441
Practice Address - Country:US
Practice Address - Phone:203-454-0505
Practice Address - Fax:203-454-1115
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001537364SP0809X
CTE35094363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT400001537CT02OtherANTHEM
CT196843OtherMHN
CT0007936120OtherAETNA
CT2083862OtherCIGNA