Basic Information
| Provider Information | |||||||||
| NPI: | 1972171783 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOSTIC | ||||||||
| FirstName: | MARCHELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2914 127TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | LAKE STEVENS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982588053 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 275 SE CABOT DR | ||||||||
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| City: | OAK HARBOR | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982773715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609145504 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2021 | ||||||||
| LastUpdateDate: | 06/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT61149299 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.