Provider Demographics
NPI:1649837352
Name:BOUDREAU, ALYCIA BUFORD (FNP-C)
Entity type:Individual
Prefix:
First Name:ALYCIA
Middle Name:BUFORD
Last Name:BOUDREAU
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19605 MORDEN BLUSH DR
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-9087
Mailing Address - Country:US
Mailing Address - Phone:813-433-3929
Mailing Address - Fax:
Practice Address - Street 1:19605 MORDEN BLUSH DR
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-9087
Practice Address - Country:US
Practice Address - Phone:813-433-3929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-29
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11002140363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily