Basic Information
Provider Information | |||||||||
NPI: | 1659989481 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOSHELL | ||||||||
FirstName: | MELANIE | ||||||||
MiddleName: | BLAIR | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | N/A | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1230 RIVER DR APT 211 | ||||||||
Address2: |   | ||||||||
City: | BELMONT | ||||||||
State: | NC | ||||||||
PostalCode: | 280123981 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2566828809 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2675 COURT DR # B | ||||||||
Address2: |   | ||||||||
City: | GASTONIA | ||||||||
State: | NC | ||||||||
PostalCode: | 280541478 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7048244999 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2020 | ||||||||
LastUpdateDate: | 07/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X |   |   | Y |   |   |   |   |
No ID Information.