Basic Information
| Provider Information | |||||||||
| NPI: | 1154657443 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUTILIER | ||||||||
| FirstName: | JENNA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27 | ||||||||
| Address2: | |||||||||
| City: | MANVILLE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028380027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009270002 | ||||||||
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| Practice Location | |||||||||
| Address1: | 106 NATE WHIPPLE HWY | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CUMBERLAND | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028641403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4016582020 | ||||||||
| FaxNumber: | 4016583612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2009 | ||||||||
| LastUpdateDate: | 10/22/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NPP37529 | RI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.