Basic Information
| Provider Information | |||||||||
| NPI: | 1487709655 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOSTIC | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 70 | ||||||||
| Address2: | |||||||||
| City: | DAWES | ||||||||
| State: | WV | ||||||||
| PostalCode: | 250540070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047342040 | ||||||||
| FaxNumber: | 3047342047 | ||||||||
| Practice Location | |||||||||
| Address1: | ROUTE 79 | ||||||||
| Address2: | |||||||||
| City: | DAWES, | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047342040 | ||||||||
| FaxNumber: | 3047342047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 03/18/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 47229RN | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7102056000 | 05 | WV | MEDICAID |