Provider Demographics
NPI:1538430939
Name:BOSTIC, NICOLE L (CRNA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:BOSTIC
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 W HIGH ST
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-4340
Mailing Address - Country:US
Mailing Address - Phone:419-998-4573
Mailing Address - Fax:419-998-4586
Practice Address - Street 1:1001 BELLEFONTAINE AVE
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-2800
Practice Address - Country:US
Practice Address - Phone:419-228-3335
Practice Address - Fax:419-998-4586
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.339224367500000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0060730Medicaid
OH0060730Medicaid