Basic Information
| Provider Information | |||||||||
| NPI: | 1710280136 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUTILIER | ||||||||
| FirstName: | CINDY | ||||||||
| MiddleName: | IRENE | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 YORK STREET CB 2041 | ||||||||
| Address2: | NORTHEAST MEDICAL GROUP | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036884748 | ||||||||
| FaxNumber: | 2036884740 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 YORK STREET CB 2041 | ||||||||
| Address2: | NORTHEAST MEDICAL GROUP | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036884748 | ||||||||
| FaxNumber: | 2036884740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2010 | ||||||||
| LastUpdateDate: | 08/17/2015 | ||||||||
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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 | 004582 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 163W00000X | 77555 | CT | N | Nursing Service Providers | Registered Nurse |
No ID Information.