Provider Demographics
NPI:1538742259
Name:BOSTIC, NOBLE (NP)
Entity type:Individual
Prefix:
First Name:NOBLE
Middle Name:
Last Name:BOSTIC
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 HUIET DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-8507
Mailing Address - Country:US
Mailing Address - Phone:860-881-6994
Mailing Address - Fax:
Practice Address - Street 1:890 HUIET DR
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252-8507
Practice Address - Country:US
Practice Address - Phone:860-881-6994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN226785363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner