Basic Information
| Provider Information | |||||||||
| NPI: | 1538244777 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOSE | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 MAGELLAN AVE | ||||||||
| Address2: | |||||||||
| City: | KINGS PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117543801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312699826 | ||||||||
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| Practice Location | |||||||||
| Address1: | 445 OAK ST | ||||||||
| Address2: | |||||||||
| City: | COPIAGUE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117263111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316917080 | ||||||||
| FaxNumber: | 6316913387 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 163W00000X | 3679801 | NY | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 3679801 | 01 | NY | LICENSE | OTHER |