Provider Demographics
NPI:1730740044
Name:BOUTON, HAILEY A
Entity type:Individual
Prefix:
First Name:HAILEY
Middle Name:A
Last Name:BOUTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HAILEY
Other - Middle Name:A
Other - Last Name:GRIMM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10200 KENAI SPUR HWY
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-7807
Mailing Address - Country:US
Mailing Address - Phone:907-283-3658
Mailing Address - Fax:907-283-5046
Practice Address - Street 1:10200 KENAI SPUR HWY
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-7807
Practice Address - Country:US
Practice Address - Phone:907-283-3658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator