Basic Information
| Provider Information | |||||||||
| NPI: | 1437533320 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOGUE | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 S B B KING BLVD # 100 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014361381 | ||||||||
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| Practice Location | |||||||||
| Address1: | 429 W LINCOLN RD | ||||||||
| Address2: | |||||||||
| City: | KOKOMO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469023508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654535600 | ||||||||
| FaxNumber: | 7654550110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2015 | ||||||||
| LastUpdateDate: | 08/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209013786 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 71005573A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 201308690 | 05 | IN | MEDICAID |