Basic Information
| Provider Information | |||||||||
| NPI: | 1609117704 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUTELLE | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | LINNEA | ||||||||
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| Credential: | RN, WHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 232410 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921932410 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 W ARBOR DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009268273 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2013 | ||||||||
| LastUpdateDate: | 09/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LX0001X | NP95000140 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology | 363L00000X | NP95000140 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LW0102X | NP95000140 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
No ID Information.