Provider Demographics
NPI:1184812703
Name:BOUCHER, LISA M
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:BOUCHER
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 1:27511 LIPPIZZAN TRL
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33950-8331
Mailing Address - Country:US
Mailing Address - Phone:941-421-2116
Mailing Address - Fax:941-421-2116
Practice Address - Street 1:265 E MARION AVE
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-3715
Practice Address - Country:US
Practice Address - Phone:941-629-8001
Practice Address - Fax:941-766-0001
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA537412471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography