Provider Demographics
NPI:1760859870
Name:BOUDAH, LYNNE
Entity type:Individual
Prefix:
First Name:LYNNE
Middle Name:
Last Name:BOUDAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:487 E WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-1338
Mailing Address - Country:US
Mailing Address - Phone:313-828-2213
Mailing Address - Fax:
Practice Address - Street 1:487 E WOODLAND ST
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-1338
Practice Address - Country:US
Practice Address - Phone:313-828-2213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703038966164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse