Basic Information
| Provider Information | |||||||||
| NPI: | 1326467945 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOGGESS | ||||||||
| FirstName: | MARQUITA | ||||||||
| MiddleName: | WALLACE | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19305 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282199305 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 501 BILLINGSLEY RD | ||||||||
| Address2: | COTTAGE B | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282111009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044445881 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2014 | ||||||||
| LastUpdateDate: | 10/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5006850 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0808X | 5006850 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.