Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | 25MP00197800 | NJ |
NPI | 1033379961 |
---|---|
Provider Name | Mrs. Melissa Woods Bouffard |
First Address | Warren, NJ 07059-5127 |
Second Address | Warren, NJ 07059-5127 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/06/2008 |
Last Update Date | 13/06/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
22-3824190 | GROUP TAX ID # (01) | NJ |