Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LC1500X | Nurse Practitioner - Community Health | 111312 | NE |
NPI | 1407131543 |
---|---|
Provider Name | Christy S Boulos |
First Address | Omaha, NE 68122-4000 |
Second Address | Omaha, NE 68111-3863 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/10/2011 |
Last Update Date | 20/10/2011 |